The Journal of Maternal-Fetal & Neonatal Medicine

ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20

Effects of folic acid supplementation during

different pregnancy periods and relationship with
the other primary prevention measures to neural
tube defects

Rui Gong, Zhi-Ping Wang, Meng Wang, Li-Jie Gao & Zhong-Tang Zhao

To cite this article: Rui Gong, Zhi-Ping Wang, Meng Wang, Li-Jie Gao & Zhong-Tang Zhao (2016):
Effects of folic acid supplementation during different pregnancy periods and relationship with
the other primary prevention measures to neural tube defects, The Journal of Maternal-Fetal &
Neonatal Medicine, DOI: 10.3109/14767058.2016.1152241

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Published online: 29 Mar 2016.

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ISSN: 1476-7058 (print), 1476-4954 (electronic)

J Matern Fetal Neonatal Med, Early Online: 1–8

! 2016 Informa UK Limited, trading as Taylor & Francis Group. DOI: 10.3109/14767058.2016.1152241

ORIGINAL ARTICLE

Effects of folic acid supplementation during different pregnancy periods

and relationship with the other primary prevention measures to neural
tube defects
Rui Gong1,2,3, Zhi-Ping Wang2, Meng Wang4, Li-Jie Gao2, and Zhong-Tang Zhao2
1
Institute of Population Research, Peking University, Beijing, China, 2Department of Epidemiology and Health Statistics, School of Public Health,
Shandong University, Jinan, China, 3China Rehabilitation Research Centre for Deaf Children, Beijing, China, 4Zhejiang Provincial Center for Disease
Control and Prevention, Hangzhou City, China
Downloaded by [Gazi University] at 13:44 03 April 2016

Abstract Keywords
Objective: To find out the prevention effects of folic acid supplements during different Anencephaly, folic acid, neural tube defects,
pregnancy periods on neural tube defects (NTDs) and the relationship of folic acid supplements periconceptional period, preventive
with the other NTDs’ primary preventive measures. measures, spina bifida
Methods: A 1:1 case-control study was conducted. Four hundred and fifty-nine women who
delivered or gestate infants/fetuses with NTDs in the last two years were randomly selected as History
cases and were matched with women who delivered babies without obvious birth defects as
controls. Received 2 October 2015
Results: For anencephaly, folic acid supplementation during the periconceptional period and Accepted 5 February 2016
preconceptional period has a 57–83% reduction in risk of NTDs(ORs ranged from 0.17 to 0.43). Published online 28 March 2016
For spina bifida, folic acid supplementation during the periconceptional period has a 79%
reduction in risk of NTDs (OR ¼ 0.21). For encephalocele, folic acid supplementation during the
periconceptional period has a 67% reduction in risk of NTDs (OR ¼ 0.33). The prevention effects
on NTDs were significant when these preventive measures combined with folic acid
supplements during the periconceptional period, with OR 0.04, 0.07, 0.10 and 0.11.
Conclusion: The specific effects of folic acid supplementation during different periods show the
reduction in the risk of NTDs, anencephaly, spina bifida, encephalocele. During periconcep-
tional period, folic acid supplements have preventive effects on all NTDs’ subtypes.

Introduction defects, which has always been considered as an important

public health issue.
Neural tube defects (NTDs) are a group of severe birth defects
A study by Smithells et al. showed that the serum folic acid
that occur early in fetal development due to the incomplete
level of women pregnant with NTDs decreases during the
closing of the neutral tube, specific types include anencepha-
early pregnancy [4]. In 1991, MRC Vitamin Study Research
lus, spina bifida and encephalocele. The prevalence of NTDs
Group conducted a large-scale multicenter and double blind
is around 1% worldwide. China is a country with a high
randomized controlled trial, which supplemented 1817
prevalence of NTDs, in 2003 it was 14% in the northern area
women, who had ever been pregnant with NTDs, with folic
[1] and the difference varied greatly across regions; for
acid during periconceptional period [5]. The results showed
example, Shanxi Province is one of the regions with a high
that after the folic acid supplements, NTDs recurrence rate
prevalence of NTDs and Shandong Province is one of the
went down by 72%. In addition, according to a large-scale
regions with a low prevalence of NTDs [2], while the
randomized controlled trial conducted among Hungarian
prevalence of NTDs was round 0.7% in the US [3]. However,
women, the supplements of multi-vitamins containing
the prevalence of NTDs does not reliably estimate the
0.8 mg folic acid could reduce the incidence of NTDs by
occurrence of NTDs, because the prevalence usually includes
93% [6]. In view of this, many countries and regions all over
stillbirths and live births, but not the terminated pregnancies.
the world have dedicated to the promotion of NTDs primary
The incidence of NTD ranks forefront among various birth
preventive measures centering on folic acid supplements since
1990s. The US introduced the grain products fortification
with folic acid in 1998. Compared with those promotional
Address for correspondence: Professor Zhong-Tang Zhao, Department of activities, food fortification with folic acid again lowered the
Epidemiology and Health Statistics, Shandong University, 44 Wenhua NTDs incidence by 20–30% on the basis of folic acid
Xilu Road, Jinan, Shandong 250012, China. Tel: +86 531 88382128.
E-mail: ztzhao@sdu.edu.cn supplements promotion [7].
 2 R. Gong et al.
However, NTDs incidence has not been decreased as
expected so far. The UK and Ireland are countries with high
NTDs incidence, and 10 years later from the implementation
of folic acid policy in 1992 and 1993, the incidence only
reduced approximately by 30% [8]. According to statistics,
about 240 000 spina bifida and anencephalus cases prevent-
able by folic acid occur in nearly 40 countries in the world
every year, while the number of cases that are actually and
successfully prevented is around 22 000, only accounting for
about 10% [9–11]. Therefore, the control on the NTDs
incidence by the preventive project of folic acid supplements
is not satisfactory. The unsatisfactory compliance with or the
low supplement rate of folic acid supplements by women of
child-bearing age comprises one reason. In 1992, the US
Department of Health and Human Services required all fertile
women of child-bearing age to take in 0.4 mg/d folic acid
supplements. According to a study in 1999, only 32.2% of
American women of child-bearing age took folic acid
supplements. Data of the year 2008 showed that the folic
acid supplement rates of American women of child-bearing
age in the years 2003, 2004, 2005 and 2007 were 32%, 40%,
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33% and 40%, respectively [12]. Besides, among a great
number of studies on NTDs prevention by folic acid, there is
much less coverage of the timing of folic acid supplements
that plays an important role in the efficacious prevention of
NTDs by folic acid.
This paper, through the 1:1 case-control study, studies the
prevention effects of folic acid intake on NTDs during
different periods, explores the relationship between folic acid
intake during different periods and the other NTD primary
preventive measures, thus laying the theoretical foundation for
the promotion of reasonable folic acid intake and the
construction of an efficacious NTD prevention mode.
Methods
Study participants
The research data is derived from the 1:1 matched case-
control study. According to the difference between Shandong
province and Shanxi province in NTDs incidence, more study
sites, 14 counties, were randomly selected from Shandong,
while six counties from Shanxi. The cases were constituted by
the women who gave birth to infants with NTDs, or who had
an induced labor or abortion due to the fetus with NTDs from
January 2006 to December 2008. All fetuses and infants with
NTDs were in accordance with the related defining features
and the diagnostic standards of congenital malformation of
central nervous system specified in ‘‘Birth Defects
Monitoring Manual of China’’. The diagnosis was confirmed
and the cases were classified by full-time doctors through the
clinical examination and ultrasonic inspection. The controls
were women who gave birth to healthy infants in the same
area, hospital and the same year as the cases.
Women whose hospital information records did not comply
with the criteria and those who did not sign the consent form
were excluded. Four hundred and fifty-nine women who gave
birth to infants suffering from NTDs or had an induced labor
or an abortion due to the fetus suffering from NTDs based on
the ultrasonic diagnosis within two years before the survey
dates that were between March and December 2008 in
J Matern Fetal Neonatal Med, Early Online: 1–8
Shandong province and Shanxi province were randomly
selected and matched with 459 normal women as controls.
Definition of research factors
Folic acid supplements comprise three circumstances: (1)
periconceptional folic acid supplements: within the three
months before pregnancy and the first three months of
pregnancy, 0.4 mg of folic acid is taken in everyday for one
month and more; (2) preconceptional folic acid supplements:
within the six months before pregnancy, 0.4 mg of folic acid is
taken in everyday for one month and more; and (3)
postconceptional folic acid supplements: within the first
three months of pregnancy, 0.4 mg of folic acid is taken in
everyday for one month and more, and no folic acid is taken
before pregnancy.
Other NTDs primary preventive measures include: (1)
genetic counseling: during the preconceptional or periconcep-
tional period, women of childbearing age conduct genetic
counseling with questions related to NTDs in formal medical
institutions; (2) pregnancy planning: women of childbearing
age have willingness to bear children, end contraception and
become pregnant in the expected period; (3) health education:
during the preconceptional or periconceptional period,
women of childbearing age accept health education related
to eugenics including related NTDs knowledge; and (4)
preconceptional examinations: before this pregnancy, women
of childbearing age have examinations for five eugenics
indicators, namely toxoplasma, rubella virus, cytomegalovirus
(CMV), herpes simplex virus I and II.
Data collection
This study adopted self-designed questionnaires. The ques-
tionnaire design went through review of literatures, panel
discussion, review and comment by experts and a trial test,
and then was revised repeatedly before being finalized. The
investigated contents mainly included demographic charac-
teristics of the participants (age, address, occupation,
education background, family income, and family size);
history of previous pregnancy (abortion, labor and induced
labor history) and history of chronic diseases, environmen-
tal and occupational risk factors exposure history (tobacco,
alcohol and hazardous substances); the situation of folic
acid supplements (the types of folic acid; the dosage every
day and the number of days of supplements within six
months before pregnancy and every month during the
pregnancy) and the implementation of other NTDs primary
preventive measures (genetic counseling, pregnancy plan-
ning, health education and preconceptional examinations).
In the case of informed consent, investigators collected
information through face-to-face interviews and health
records checking. Investigators were postgraduates of
Shandong University, who had been trained for unified
standard interviewing and were proved qualified through
the examination before investigation.
Statistical analysis
Database was set up after the quality check of source data.
Double entry and logical consistency check were conducted to
 DOI: 10.3109/14767058.2016.1152241 Effects of folic acid on NTDs 3

ensure the accuracy. The software SAS 9.1.3 was used for
statistical processing.
Frequency and proportion were used to describe demo-
graphic characteristics data and the implementation of folic
acid supplements and other NTDs primary preventive meas-
ures. The conditional logistic regression model was used to
analyze the efficacy of folic acid supplements during different
periods by women of childbearing age and that of other NTDs
primary preventive measures; the values of efficacy were
indicated by OR and OR 95% CI. The unconditional logistic
regression model was used to analyze the influencing factors of
folic acid supplements during different periods by women of
childbearing age and to analyze the combined effects of folic
acid supplements during different periods and other NTDs
primary preventive measures. The test level was  ¼ 0.05.
Results
Demographic characteristics of participants
Among the investigated 459 pairs of women, the minimum
childbearing age was 18, the maximum 47 and the mean 29.2
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was not significant on the occurrence of NTDs; the influence
of occupation was significant, and the occupation of farmers’
was higher than others (p50.01); the influence of average
annual family income was significant, higher income with
lower NTDs occurrence (p50.001); and the influence of
education degree was also significant, higher degree with
lower occurrence (p50.001) (Table 1).
In addition, there was a significant difference between the
case group and the control group in childbearing history of
birth defects (p ¼ 0.007, OR ¼ 7.500), family history of birth
defects (p ¼ 0.004, OR ¼ 3.000), preconceptional chronic
disease history (p ¼ 0.014, OR ¼ 2.333) and preconceptional
hazardous substances exposure (p 5 0.001, OR ¼ 6.000)
(Table 1).
Preventive effects of folic acid supplements during
different periods on NTDs all subtypes
In the case group, a total of 30.7% had folic acid supplements,
23 of whom did this during the periconceptional period
(accounting for 5%), 18 of whom during the preconceptional

in the case group, while in the control group, the minimum
childbearing age was 19, the maximum 47 and the mean 28.4.
The education background of most participants was middle
school, accounting for 66.5%. Among the 459 infants or
fetuses with NTDs, 184 were spina bifida cases (accounting
for 40.1%), 165 were anencephalus cases (35.9%), 65 were
encephalocele cases (14.2%) and 45 were complex malfor-
mation (9.8%). Analyzed by univariate conditional logistic
regression model, the influence of women’s childbearing age
period (3.9%), and 100 of whom during the postconceptional
period (21.8%). In the control group, a total of 50.1% had folic
acid supplements, 79 of whom did this during the periconcep-
tional period (accounting for 17.2%), 27 of whom only during
the preconceptional period (5.9%), and 124 of whom during
the postconceptional period (27%). In the case group, the
implementation rate of health education was 52.9%, that of
pregnancy planning 28.4%, that of preconceptional examin-
ations 17.6%, and that of genetic counseling only 12.9%.

Table 1. Demographic characteristics of participants and its relations with NTDs.

NTD cases Controls

Variance n %* n %* p
Age at conception
23 77 16.8 81 17.6 0.069
23–28 188 41.0 219 47.7
428 194 42.3 159 34.6
Periconceptional occupation
Farmer 349 76.0 329 71.7 0.003
Factory worker 57 12.4 35 7.6
Business/officer/soldier/technologist 53 11.5 95 20.7
Annual per capita income
3600 232 50.5 175 38.1 0.000
3600–7200 159 34.6 164 35.7
47200 68 14.8 120 26.1
Education completed
5Middle school graduate 119 25.9 46 10.0 0.000
Middle school graduate 298 64.9 312 68.0
4Middle school graduate 42 9.2 101 22.0
Childbearing history of birth defects
No 444 96.7 457 99.6 0.007
Yes 15 3.3 2 0.4
Family history of birth defects
No 432 94.1 450 98.0 0.004
Yes 27 5.9 9 2.0
Preconceptional chronic disease
No 429 93.5 445 96.9 0.014
Yes 30 6.5 14 3.1
Preconceptional hazardous substances exposure
No 356 77.6 436 95.0 0.000
Yes 103 22.4 23 5.0

*Percentages may not equal 100 because of missing data or rounding.

 4 R. Gong et al. J Matern Fetal Neonatal Med, Early Online: 1–8

According to the analysis of univariate conditional logistic
regression model, folic acid supplements during different
periods all had significant preventive effects on NTDs, among
which the effects of the supplements during the periconcep-
tional period were the most significant (OR ¼ 0.21, OR 95%
CI ¼ 0.13, 0.34), and the supplements during the preconcep-
tional period (OR ¼ 0.48, OR 95% CI ¼ 0.26, 0.89) and the
postconceptional period came next (OR ¼ 0.58, OR 95%
CI ¼ 0.42, 0.72); the preventive effects of genetic counseling
on NTDs were not significant (p40.05); and additionally,
pregnancy planning (p50.001), health education (p50.001),
premarital examinations (p50.01) and preconceptional exam-
inations (p50.001) had significant preventive effects on
NTDs, among which health education and preconceptional
examinations had the most significant effects (OR ¼ 0.25, OR
95% CI ¼ 0.18, 0.36; OR ¼ 0.36, OR 95% CI ¼ 0.26, 0.51)
(Table 2).
Analyzed by multivariate conditional logistic regression
model including NTDs primary preventive measures, com-
pared to women who did not take folic acid supplements, the
risks of NTDs for women who were supplemented with folic
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null). For encephalocele, a 67% reduction in risk of NTDs was
observed at folic acid during the periconceptional period
(OR ¼ 0.33 and the 95% CIs did not include the null).
The promotion of other NTDs primary preventive
measures on folic acid supplements during different
periods
After adjusting the influence of maternal age, education,
occupation, annual family income, childbearing history of
birth defects, family history of birth defects, preconceptional
chronic disease and hazardous substances exposure, the
analysis of unconditional logistic regression model showed
the following:
In the case group, the proportion of folic acid supplements
during the periconceptional period by women who conducted
pregnancy planning, health education or preconceptional
examinations was significantly higher than that of supple-
ments by women who did not carry out these items, the values
of OR being 3.83 (OR 95% CI ¼ 1.19, 12.34), 3.43 (OR 95%
CI ¼ 1.20, 9.83) and 4.37 (OR 95% CI ¼ 1.68, 11.34),

acid during the periconceptional period decreased by 5.9
times (OR ¼ 0.17, OR 95% CI ¼ 0.08, 0.36), and the risks for
those who took folic acid only during the preconceptional
period and only during the postconceptional period were
reduced by 2.7 times and 1.8 times, respectively, as shown in
Table 3.
Table 3 further shows the specific effects of folic acid
supplementation during different periods on the risk of NTDs,
anencephaly, spina bifida and encephalocele. For total NTDs,
a 43–83% reduction in risk of NTDs was observed at folic
acid during different periods (ORs ranged from 0.17 to 0.57
and the 95% CIs did not include the null). For anencephaly, a
57–83% reduction in risk of NTDs was observed at folic acid
during the periconceptional period and preconceptional
period (ORs ranged from 0.17 to 0.43 and the 95% CIs did
not include the null). For spina bifida, a 79% reduction in risk
of NTDs was observed at folic acid during the periconcep-
tional period (OR ¼ 0.21 and the 95% CIs did not include the
respectively. Additionally, the proportion of folic acid
supplements only during the preconceptional period by
women who had pregnancy planning or preconceptional
examinations was significantly higher than those who did not
do so, OR of which was 4.65 (OR 95% CI ¼ 1.22, 17.77) and
5.44 (OR 95% CI ¼ 1.64, 18.02); and health education was
positively correlated with folic acid supplements only
during the postconceptional period (OR ¼ 1.97, OR 95%
CI ¼ 1.17, 3.21).
In the control group, compared with women who did not
implement health education, the proportion of folic acid
supplements during the periconceptional period and only
during the preconceptional period by those who had health
education rose by 8.01 times (OR 95% CI ¼ 2.38, 26.97) and
9.18 times, respectively (OR 95% CI ¼ 1.19, 70.82). The
proportion of folic acid supplements during the periconcep-
tional period by women who had genetic counseling or
pregnancy planning was significantly higher than that of those

Table 2. Relationships between folic acid supplementation during different periods, other NTDs primary preventive measures and
NTDs: univariate conditional logistic regression analysis.

NTD cases Controls OR 95% CI

Variance n % n % p OR Lower Upper
Folic acid intake
None 318 69.3 229 49.9 Reference
Periconceptional 23 5.0 79 17.2 0.000 0.21 0.13 0.34
Preconceptional 18 3.9 27 5.9 0.018 0.48 0.26 0.89
Postconceptional 100 21.8 124 27.0 0.001 0.58 0.42 0.72
Genetic counseling
No 400 87.1 388 84.5 Reference
Yes 59 12.9 71 15.5 0.202 0.76 0.50 1.16
Pregnancy planning
No 249 71.6 206 59.4 Reference
Yes 99 28.4 141 40.6 0.000 0.52 0.36 0.74
Health education
No 216 47.1 92 20.0 Reference
Yes 243 52.9 367 80.0 0.000 0.25 0.18 0.36
Preconception examinations
No 378 82.4 295 64.4 Reference
Yes 81 17.6 163 35.6 0.000 0.36 0.26 0.51
 DOI: 10.3109/14767058.2016.1152241 Effects of folic acid on NTDs 5
Table 3. Effects of folic acid supplementation during different periods on all NTDs, anencephaly, spina bifida and
encephalocele.

NTDs Anencephaly Spina bifida Encephalocele

Folic acid intake OR* 95% CI OR* 95% CI OR* 95% CI OR* 95% CI
None Reference Reference Reference Reference
Periconceptional 0.17 0.08–0.36 0.17 0.08–0.35 0.21 0.10–0.45 0.33 0.14–0.80
Preconceptional 0.37 0.14–0.95 0.43 0.28–0.65 0.53 0.22–1.26 0.48 0.14–1.65
Postconceptional 0.57 0.32–0.98 0.45 0.20–1.01 0.75 0.50–1.12 0.70 0.40–1.22

*Adjusted for maternal age, education, occupation, annual family income, childbearing history of birth defects, family history
of birth defects, preconceptional chronic disease and hazardous substances exposure, genetic counseling, pregnancy
planning, health education and preconception examinations

Table 4. Influencing factors of folic acid supplementation during different periods.

Folic acid intake

Periconceptional Preconceptional Postconceptional
ORy ORy ORy
Other primary preventive measures n % 95.0% CI n % 95.0% CI n % 95.0% CI
In the NTDs group
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Genetic counseling
No 20 87.0 1.03 17 94.4 0.5 85 85.0 1.29
Yes 3 13.0 0.27, 3.87 1 5.6 0.06, 4.17 15 15.0 0.66, 2.52
Pregnancy planning
No 7 46.7 3.83 6 40.0 4.65 46 66.7 1.78
Yes 8 53.3 1.19, 12.34 9 60.0 1.22, 17.77 23 33.3 0.91, 3.48
Health education
No 6 26.1 3.43 6 33.3 2.8 37 37.0 1.94
Yes 17 73.9 1.20, 9.83 12 66.7 0.86, 9.14 63 63.0 1.17, 3.21
Preconception examinations
No 13 56.5 4.37 11 61.1 5.44 82 82.0 1.41
Yes 10 43.5 1.68, 11.34 7 38.9 1.64, 18.02 18 18.0 0.75, 2.63
In the control group
Genetic counseling
No 53 67.1 4.22 23 85.2 1.83 105 84.7 1.7
Yes 26 32.9 2.12, 8.40 4 14.8 0.55, 6.06 19 15.3 0.83, 3.45
Pregnancy planning
No 27 39.1 3.28 11 50.0 2.46 52 61.2 0.93
Yes 42 60.9 1.74, 6.19 11 50.0 0.96, 6.34 33 38.8 0.50, 1.74
Health education
No 4 5.1 8.01 1 3.7 9.18 24 19.4 1.12
Yes 75 94.9 2.38, 26.97 26 96.3 1.19, 70.82 100 80.6 0.63, 1.99
Preconception examinations
No 48 60.8 1.35 15 55.6 1.85 71 57.3 1.46
Yes 31 39.2 0.76, 2.41 12 44.4 0.78, 4.40 53 42.7 0.89, 2.41
yAdjusted for maternal age, education, occupation, annual family income, childbearing history of birth defects, family history of birth defects,
preconceptional chronic disease and hazardous substances exposure

who did not, OR being 4.22 (OR 95% CI ¼ 2.12, 8.40) and
3.28 (OR 95% CI ¼ 1.74, 6.19), respectively. The results are
shown in Table 4.
Combined effects of folic acid supplements during
different periods and other NTDs primary preventive
measures on NTDs
After adjusting the influence of maternal age, education,
occupation, annual family income, childbearing history of
birth defects, family history of birth defects, preconceptional
chronic disease and hazardous substances exposure, the
unconditional logistic regression model showed that com-
pared with women who did not implement any other NTDs
primary preventive measures or take any folic acid, genetic
counseling, pregnancy planning, health education or pre-
conceptional examinations and folic acid supplements during
different periods had significant combined effects on NTDs
prevention (Table 5) and the effects were greatest when the
other primary preventive measures were combined with folic
acid supplements during the periconceptional period, with the
lowest OR, which were 0.04 (OR 95% CI ¼ 0.01, 0.17), 0.07
(OR 95% CI ¼ 0.02, 0.18), 0.10 (OR 95% CI ¼ 0.04, 0.21),
and 0.11 (OR 95% CI ¼ 0.04, 0.30), respectively. The
combined effects with folic acid supplements only during
the preconceptional period were the second greatest. Besides,
the risk of NTDs was minimum when both folic acid
supplements during the periconceptional period and genetic
counseling were implemented, reduced by 96% compared
with the case that neither folic acid supplements nor any
 6 R. Gong et al. J Matern Fetal Neonatal Med, Early Online: 1–8

Table 5. Combined effects of folic acid intake during different periods and other primary preventive measures by women
of childbearing age on NTDs.

Folic acid intake

Other primary measures None Periconceptional Preconceptional Postconceptional
None
No. of cases/no. of controls 84/32 1/1 0/2 15/14
OR* Reference 0.27 N/Ay 0.44
95.0% CI 0.02–4.97 0.18–1.05
Genetic counseling
No. of cases/no. of controls 40/22 3/26 1/4 15/19
OR* 0.69 0.04 0.10 0.38
95.0% CI 0.34–1.37 0.01–0.17 0.01–0.95 0.15–0.83
Pregnancy planning
No. of cases/no. of controls 59/55 8/42 9/11 23/33
OR* 0.36 0.07 0.19 0.34
95.0% CI 0.20–0.67 0.02–0.18 0.06–0.61 0.15–0.75
Health education
No. of cases/no. of controls 151/166 17/75 12/26 63/100
OR* 0.40 0.10 0.12 0.32
95.0% CI 0.25–0.66 0.04–0.21 0.05–0.31 0.18–0.57
Preconceptional examinations
No. of cases/no. of controls 46/67 10/31 7/12 18/53
OR* 0.29 0.11 0.19 0.19
95.0% CI 0.16–0.52 0.04–0.30 0.06–0.62 0.09–0.39
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*Adjusted for maternal age, education, occupation, annual family income, childbearing history of birth defects, family
history of birth defects, preconceptional chronic disease and hazardous substances exposure.
yN/A, not applicable.

Figure 1. Effect estimates of folic acid

supplements during different periods and
other NTDs primary preventive measures on
NTDs (odds ratios).

other NTDs primary preventive measure was implemented
(Figure 1).
Discussion
The present study showed that folic acid supplements by
women of childbearing age during different periods, including
the periconceptional, only preconceptional and only post-
conceptional periods, had significant prevention effects on
NTDs, among which the supplements during the periconcep-
tional period had the greatest effects, reducing NTDs risks by
six times compared with women who did not take folic acid
supplements. The folic acid supplements only in the
preconceptional period could also prevent NTDs effectively,
reducing the risks by 2.7 times. It is thus clear that the folic
acid supplements by women of childbearing age can effect-
ively prevent NTDs, which is consistent with results of other
studies. It has been proved in many retrospective case-control
studies that folic acid supplements has preventive effects on
NTDs [13–16], OR for NTDs decrease around 0.6 and 0.7,
and also many cohort studies and experimental studies have
proved that taking folic acid supplements in the periconcep-
tional period can lower NTDs, OR ranging from 0.1 to 0.6
[17,18].
However, the incidence of NTDs in the population has not
decreased as expected. European countries have high
 DOI: 10.3109/14767058.2016.1152241
incidence of NTDs, and it has lowered less than 30% since
10 years after the folic acid supplements policy was
implemented [8]. Some monitoring data shows that NTDs
that have been successfully prevented are less than 10% [9–
11]. Therefore, the control of folic acid supplements on
NTDs incidence currently is not satisfactory. Bad compli-
ance with folic acid supplements and the low rate of folic
acid supplements by women of childbearing age are
probably the reason for the unsatisfactory prevention
effects. In addition, the timing of folic acid intake and
the way to promote it are also important factors for
efficacious NTDs prevention by folic acid.
In the present study, the rate of compliance and imple-
mentation of folic acid supplements were very low. In the case
group, the rate of folic acid supplements was 30.7%. Of this
figure, only 5% was during the periconceptional period, lower
than 4% was during the preconceptional period and most of it
was during the postconceptional period. While in the control
group, the rate of folic acid supplements was 50%, of which
the rate of folic acid supplements during the periconceptional
period was less than 20% and the rate in preconceptional
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period did not reach 6%. This data was lower than the
supplement rate by American women of childbearing age in
2007, which was 40% [12]. In addition, the research data
about Mexican women (including 385 Mexican subjects) by
Shaw et al. showed that the use of vitamin containing folic
acid only accounted for 5– 6% [19].
This study found that the positive correlation existed
between genetic counseling, pregnancy planning, health
education and preconceptional examinations and folic acid
supplements by women of childbearing age. In the case group,
genetic counseling, pregnancy planning and health education
could significantly improve the ratio of folic acid supplements
during the periconceptional period by four times. Pregnancy
planning and preconceptional examinations also increased the
folic acid supplement rate in the preconceptional period by
five times. Some Hungarian data show that pregnancy
planning increased the rate of folic acid supplements by
women of childbearing age and the supplement rate by
women with pregnancy planning was 13 times that of women
without it [20]. Furthermore, in the control group, the
implementation of genetic counseling and health education
could improve the folic acid supplements in the periconcep-
tional period by 4–8 times.
Moreover, this research data shows that for NTDs preven-
tion, synergetic effects existed between other NTDs primary
preventive measures, such as genetic counseling, pregnancy
planning, health education and preconceptional examinations,
and folic acid supplements during different periods, among
which the synergetic effects between NTDs primary prevent-
ive measures and folic acid supplements during the
periconceptional period were greatest, OR ranging from
0.04 to 0.11, and the effects of folic acid supplements in the
preconceptional period were the second greatest, OR from
0.10 to 0.19. This study also showed that the prevention
effects were greatest by both implementing folic acid
supplements during the periconceptional period and genetic
counseling, reducing the risks of NTDs by 96%.
It can be seen that as for the effective control of NTDs
incidence, not only should the knowledge of folic acid
Effects of folic acid on NTDs 7
supplements and the correct rational supplements be pro-
moted among women of childbearing age, but also other
NTDs primary preventive measures should be promoted and
implemented, such as genetic counseling, pregnancy plan-
ning, health education and preconceptional examinations.
What is more, probably the effects of promoting folic acid
supplements during genetic counseling, health education and
preconceptional examinations among women of childbearing
age are greater, which can better bring the effects of all NTDs
preventive measures into play and control the NTDs incidence
effectively.
The limitations of this study are as follows. First, the
control group only includes women who had normal healthy
infants, but not those who aborted or had problem pregnancies
for reasons other than NTDs, which might lead to selection
bias. Next, there is a difference in recall bias between the case
group and the control group, which is because the age of
infants or the gestational age was not matched. Considering
that the pregnancy affected by NTDs would be terminated
early, women in the control group had longer recall of the past
than the cases. Although the researchers chose cases of only
two years before the investigating dates, the bias still exists.
Additionally, in the case-control study, it is very difficult to
measure the dosage, form and timing of folic acid supple-
ments accurately, while randomized controlled trials can
better determine these factors. Thus, further studies are
required to address these issues.
Acknowledgements
This work was supported by the project of Effectiveness
Evaluation of Hospital-Based Comprehensive Birth Defects
Intervention Methods, Ministry of Science and Technology,
China (2006BA105A01), and China Postdoctoral Science
Foundation funded project (2013M540005).
Declaration of interest
The authors declare that they have no competing interests.
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