Attitude and Practice of Folic Acid Consumption Among Saudi Pregnant Women at Yanbu City, Kingdom of Saudi Arabia

Background Folic acid (FA) intake is important for pregnant women for the healthy growth and development of their babies. It is well known that the intake of FA before and during pregnancy help in reducing the risks of congenital anomalies. Methods A quantitative cross-sectional design was used to assess pregnant women's attitudes and practices related to FA. This study was conducted in the Antenatal Clinic at Yanbu General Hospital from February 2021 to May 2021. Structured questionnaires were used for data collection from a sample of pregnant women (n=65). Results The study revealed that less than half of the study sample consumed FA daily and only 46.2% of women started consuming FA during the first month of pregnancy. Conclusion Action should be taken by the Saudi Health Organization for empowering child-bearing women to consume adequate sources of FA at the appropriate time and frequency.


Introduction
Folic acid (FA) intake is important for pregnant women for the healthy growth and development of their babies. It is well known that the intake of FA before and during pregnancy helps in reducing the risks of congenital anomalies. FA reduces homocysteine levels in the blood. In the 1930s-1940s, Lucy Willis, a physician, discovered FA supplements after conducting anemia-based tests among women in India [1]. Spina bifida is particularly common in the Kingdom of Saudi Arabia (KSA), affecting 1.2 in 1000 people [2]. Improvements in pregnancy outcomes reduce neural tube defects (NTDs), morbidities, and mortalities involving neonates or their mothers.
Pregnant women attending antenatal clinics can access knowledge from nurses, doctors, and gynecologists regarding the intake, use, dosage, and required administration of FA [3]. Moreover, healthcare professionals play a critical role in the intake of FA to enhance pregnancy outcomes for women under their care. Getting the right dosage of FA is crucial for pregnant women. It was reported that pregnant women should take 400 µg of folate per day during the periconceptional period [4]. Using FA supplements before and after pregnancy is imperative to mitigate the risk of preterm births and small for gestational age (SGA). Dietary folate intake should complement the supplements before and after the pregnancy period.
Different scholars have assessed the knowledge of FA among females. A study with 96 participants showed a low intake of FA, as only 16%, and 7% admitted the consumption of multivitamins and FA supplements, respectively [5]. According to the researchers, at least 71% of the learners consumed multivitamins during pregnancy while 54% understood food sources of FA. The research showed an understanding of FA and its impact on pregnancy, including the reduction of neural tube defects (NTDs), among the participants.
The outcomes of questionnaire-based cross-sectional studies are aligned with the findings [6,7]. Both studies agreed on the need for increasing the use of FA among females in KSA. A sample of 254 Saudi pregnant women from the Family Medicine Department revealed that only 22% of the pregnant women used it before conception [6]. Additionally, only 50% of the women understood the exact reason for FA diet or supplementation during pregnancy. This indicated the need for an increased level of awareness among Saudi women on FA supplementation during the preconception period.
The level of awareness of FA supplementation or diet intake during preconception varies from region to region. A study using a sample of 300 childbearing married women aged 19-45 years in the Hail region of KSA found that 84% used FA during different pregnancy phases [8]. A Saudi study has reported that the majority of their study sample had a poor total score on knowledge about FA, which may negatively affect FA consumption [9]. Based on the literature review undertaken, no studies have been conducted in relation to FA attitude and practice in Yanbu City, KSA. This could be due to the fact that Yanbu is a small city, which may hinder researchers from conducting their research there. Therefore, the current study aims to assess Saudi pregnant women's attitudes and practices in Yanbu City, KSA.

Study design
One of the essential steps in conducting a research study is selecting a suitable design. The design helps the researcher achieve the research aim and objectives. In the current study a quantitative, cross-sectional design was applied to assess the attitudes and practices related to FA consumption among pregnant women in Yanbu City. This type of design helps the researchers to examine the relationships and/or differences among variables.

Setting
The research setting is the physical, social, and cultural location where a study is conducted. This study was conducted at Yanbu City in KSA, which is a small and beautiful city located in the Western province of KSA. Data collection started in February 2021 and lasted until May 2021 in the Antenatal Clinic at Yanbu General Hospital (YGH). YGH was selected by the researchers because it is the largest hospital in Yanbu City and is the only governmental hospital in this region. In addition, it has a good capacity for maternal cases, which could help obtain the target population for the study. The working hours in the clinic are 08:00 AM to 04:00 PM, 5 days a week. The researcher visited the antenatal clinic daily for data collection during the period.

Sampling
The sampling design involved the selection of the subjects as study samples from the population under study. A purposeful sampling method was used to select the study participants in this study. The population of this study included (a) Saudi pregnant women attending the Antenatal Clinic at YGH; (b) aged 18-45 years; (c) living in Yanbu City; (d) willing to participate in the study. A total of 65 pregnant women were included in the current study.

Study tool
The tool of this study was a structured questionnaire developed by the researchers concerning the comprehensive reading of the related literature, and it was then revised by two academic professors specializing in maternity health in the Nursing Faculty at KAU. The questionnaire was piloted on seven selected women to assess the clarity and the time needed to fill it. In addition, reliability was tested using Cronbach's Alpha (α) test, which confirmed that the scales used in the questionnaire items are reliable. The questionnaire consisted of three parts: i) Demographic data and obstetric history; ii) Attitude toward FA; iii) Practice toward FA. The structured questionnaires were filled out by the study participants when they were in the clinic waiting area. Those who could not read or write were supported by other women who visited the clinic to help them in filling the questionnaire.

Data analysis
The questionnaire was coded and analyzed using Statistical Package for Social Sciences (SPSS) version 25 (IBM Corp., Armonk, NY). Data were presented in tables in the form of frequencies and percentages. A Chisquare test of significance with a 95% confidence level was used to find the association between variables. The attitude was classified as positive or negative. A positive attitude was defined as the study participants preferring to consume FA from both sources, natural and supplements. Practice was scored as excellent (>60.0%), good (60-40%), and poor (<40.0%). Excellent practice was defined when the study participants took FA in the first trimester of their current pregnancy, daily, and started to take it three months before their pregnancy. The researcher obtained verbal consent from the study participants, who were informed that they have the right to withdraw from the study at any point in time.      Participants' practices of FA Table 4 shows that the majority (92.3%) of the participants took FA in their current pregnancy. However, only 31.7% took FA daily in their current pregnancy. In addition, 46.2 % of the participants started to take FA in the first month of their pregnancy while 30.7 % of them started to take it three months before their pregnancy. In addition, 3.1% of the participants did not take FA during this pregnancy because they did not care about it, 1.5% of them did not take it because they take it from natural sources only, and another 1.5% did not take it because they forgot to take it.  Moreover, 26.6 % of the participants did not take FA three months before their pregnancy because they did not know its importance, 18.3% of them did not take it because they did not plan for the pregnancy while 13.3 % of them did not take FA three months before pregnancy due to other causes. The majority of the study sample received information about FA from their physician (72.3). While 64.6% of them took FA through a physician's prescription and 27.7% of them took it by buying it from a pharmacy. Table 5 shows that there is a significant association between taking FA in the current pregnancy and the participants' income. The post hoc test showed that with a higher level of income, the possibility of taking FA increases (p<0.01); 95.8% of the participants having an income of more than 9,000 SAR took FA while only 4.2% of them did not. Moreover, 73.3% of those having an income between 7,000 and 9,000 SAR took FA compared to 26.7% who did not. On the other hand, there is no significant association between taking FA in the current pregnancy and the participants' age, residence, marital status, education, and employment (p>0.05).

Relation between taking FA in current pregnancy and sociodemographic data
Taking FA in the current pregnancy  Relation between taking FA three months before pregnancy and sociodemographic data Table 6 shows the participants' practices and demographic data. It shows that there is a significant relation between taking FA three months before pregnancy and the participants' employment status. Housewives tend to take FA three months before pregnancy significantly more than working women (p<0.05). In addition, there is a significant association between taking FA three months before pregnancy and the participants' education. With more educational qualifications, the tendency to take FA three months before pregnancy decreases (p<0.05); 65.6% of the participants who have a university degree did not take FA three months before pregnancy compared to 34.4% who did.  Furthermore, there is a significant relation between taking FA three months before pregnancy and the participants' income. With more income, the tendency to take FA three months before pregnancy decreases (p<0.01); 58.3% of the participants who have an income of more than 9000 SAR did not take FA three months before pregnancy compared to 41.7% who did. On the other hand, there is no significant association between taking FA three months before pregnancy and the participants' age, residence, and marital status (p>0.05).  Relation between the attitude of taking FA from a natural source only and socio-demographic data Table 8 shows the relationship between the participants' attitudes and socio-demographic data. It shows that there is no significant association between the preference to take FA from natural sources only and the participants' age, residence, income, educational level, and employment status (p>0.01).

Relation between taking FA daily and socio-demographic data
Prefer to take FA from natural sources only  Relation between the attitude of taking FA from a complementary source only and socio-demographic data Table 9 shows the relation between the participants' attitudes and socio-demographic data. It shows that there is no significant association between the participants' preference to take FA from complementary sources only and their age, residence, income, educational level, and employment status (p>0.01).  Relation between the attitude toward taking FA from both sources and socio-demographic data Table 10 shows the relationship between participants' attitudes and demographic data. It shows that there is no significant association between the participants' preference to take FA from natural and complementary sources and their age, residence, income, educational level, and employment status (p>0.01).

Discussion
This current study assesses the attitude and practice regarding FA consumption among women of childbearing age in Yanbu City, KSA. It concluded that, generally, there is a positive attitude and slightly good practice regarding FA consumption in the most vulnerable group, which is women of childbearing age. Despite the fact that the majority of the study sample prefer to take FA from both natural and supplementation sources, it was found that more than half of the participants preferred to take FA as a supplement only and a few others preferred it in the form of food rich in folate. The outcomes are congruent with the results of another study [10]. This indicates that some participants need to be educated about the importance of both sources of FA during pregnancy.
The majority of the participants of this current study used FA during pregnancy. This finding agrees with that of another study conducted in Riyadh, KSA, which found that most of the study participants took FA during pregnancy [6]. In addition, a study found that women aged 18-60 years in Riyadh, KSA, used dietary supplementation of FA [11]. Another study also reported similar findings [12]. In contrast, a study conducted in India reported that the use of FA among pregnant women was low, which consequently led to an increase in NTDs [13]. The reason for increased FA consumption by pregnant women in the current and other Saudi studies could be that KSA health policy strictly encourages FA intake during antenatal care visits. It is worth mentioning that Saudi governmental hospitals routinely advise pregnant women to take FA and give free FA supplements. Currently, in KSA, there is an increase in empowering women's education and involvement in the workforce, which can likely attribute to better FA use.
Regarding the daily use of FA during pregnancy, the current study revealed that less than half of the study sample consumed FA daily. The same result was observed in China, which found that less than 50% of women consumed FA regularly [14]. The possible reason for this could be that the women didn't have adequate information about the proper time of FA intake or they forget to take it. On the contrary, a study revealed that 80% of the study sample used FA daily, and they found a relationship between the educational level and daily consumption of FA [15].
A study has associated educational sessions with the elimination of knowledge gaps created by societies owing to negative beliefs about the effectiveness of FA supplements besides natural sources of vitamins [16]. This study's findings are supported by another study that found increased use of FA supplements in 55.8% of the 360 studied pregnant women in Riyadh following interactions with pharmacists [17]. It can be thus argued that education is important for providing opportunities to positively influence individual knowledge, awareness, and attitudes. Therefore, health care providers should emphasize providing women with focused education, particularly during the premarital and antenatal periods, in order to improve their attitudes and practice concerning FA. However, a study conducted in KSA found that 77% of pregnant women with epilepsy took FA daily [18]. In this study, no relation between educational level and daily intake of FA was found.
Regarding FA use three months before pregnancy, a low percentage of the current sample took FA three months before conception. The outcomes are consistent with the finding of another study in KSA [6]; they reported that only 10% of the study participants took FA three months before conception. The present study found a significant relation between taking FA three months before pregnancy and the participants' employment status. It was found that a significant number of housewives took FA three months before pregnancy than working women. This could be because of the busy routine of working women. Another reason could be that housewives plan their pregnancies better as compared with working women. However, this reason was not investigated in this study and thus needs further exploration.
Similarly, a study found that 41.5% of their study samples took FA during the preconception period while 47.4% took it during pregnancy [19]. This result was found to be associated with the education level, planning for pregnancy, and the pregnancy experience. However, various studies have found that most participants took FA before pregnancy [20,21].
The current data shows that 46.2% of women started consuming FA during the first month of pregnancy. A study found a relatively similar result [22]; more than half of the study sample consumed FA during the first month of pregnancy. It can be argued that although the study participants of the current study used FA during pregnancy, the time and frequency of use were not as per the recommended standard, which limited the benefits of FA use. Insufficient FA can increase the risk of NTDs and folate deficiency anemia; it occurs in the early phase of pregnancy before the mother probably even realizes that she is pregnant. Therefore, the daily use of at least 400 μg of FA three months before conception, and the first three months of pregnancy is important in order to protect the health of mothers and their babies.
The current study has some limitations that should be considered in future studies. The generalizability of the current study was affected. First, the study sample was small this could be because the study was conducted during the COVID-19 pandemic, which may limit the number of pregnant women who visited the clinic and accepted to participate in the study. Second, this study was exclusively on women visiting YGH outpatient clinics. Therefore, further studies should be conducted with large sample sizes and various geographical settings to establish the generalizability of the result. In addition, it is worth mentioning that this study did not investigate the participant's diets and beverages they consumed daily in order to assess their actual FA consumption, which would be good for further research.

Conclusions
FA is the most important vitamin taken during pregnancy. The results of this study are in line with other national and international studies in relation to FA consumption by pregnant women. The study participants had a positive attitude and slightly good practice in relation to FA consumption. Income and employment status have an influence on FA attitude and practice. The majority of the participants took FA in their current pregnancy, however, more than half of them did not take it daily in their current pregnancy and half of them did not take FA three months before their pregnancy. Mothers should consume FA daily and before pregnancy and from both natural and complementary sources in order to optimize the enhancement of maternal and fetal health. Further action should be taken by Saudi health organizations in empowering mothers to take an adequate source of FA at the appropriate time and frequency.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Nursing Faculty at King Abdulaziz University issued approval (Ref. No. 1M.10). Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.