Intake of folic acid at least one month before pregnancy and the entire first trimester is highly recommended to decrease birth defects, particularly NTDs [10, 17, 36]. But, the prevalence of folic acid usage at the recommended time in Adama, Ethiopia was found to be 1.92%. Ethiopia is one of the developing countries where the incidence of NTDs is highly prevalent and where 1/3 of women were affected by folate deficiency [10, 19].
In the present study, pregnancy was planned by 71% of the interviewed women, which was consistent with the planning of pregnancy in Croatia . It was higher than usual reports of 50% of pregnancies, being unplanned [7, 16, 34].
Of those women who planned pregnancy 69% used contraceptive and 30.4% inform the healthcare provider before ceasing the contraceptive. As compared to survey in Europe, where 18% of the women were consulted healthcare provider prior to stopping contraceptive, the finding in this study was higher . About 11.3% of the women consulted healthcare providers, particularly about their pregnancy when they plan to become pregnant. Despite all these convenient conditions to give a folic acid supplement only 2.7% of the planning women were prescribed for folic acid during the protective period against NTD, which was very low as compared with 21% usage in Croatia that had similar levels of planned pregnancy .
Even though the number of women who consulted healthcare providers prior to stopping contraceptive in the present study was higher than surveyed women in Europe, usage in Ethiopian women was extremely low as compared to usage by 28% plan to become pregnant and 55% pregnant women in Europe .
In this study, 1.92% of the women were diabetic, 0.7% women had previous history of NTD pregnancies, both of which are high risk factors for occurrence and recurrence of NTD . However, none of them were user of folic acid at the recommended time. This finding was in contrast to the study done in Nigeria, where 40% of women with a previous history of NTD pregnancy were the user at protective period .This difference may be because of the difference in health policy, i.e. there is preconception care in Nigeria but not in Ethiopia .
The occurrence of NTDs among spontaneously aborted fetuses is 10-fold higher than the rate of NTDs at birth . In this study, 15.1% of the study subject had at least one spontaneous abortion in their lifetime. So those women are at high risk for having a baby affected by NTDs.
Women whose age were above 25 were 9.4 fold user of folic acid at protective period than women age 25 and below which was consistent with other studies in USA [27, 34], Croatia , Lebanon , and Tanzania . This finding was in contrast to the other study in Lebanese where young women were more user .
Early timing of antenatal registration and number of ANC visits also positively associated with folic acid usage for NTD prevention as other studies done in Tanzania, India, Honduras [29, 30, 35].The study findings were consistent with other studies who have reported that the level of folic acid awareness predicts folic acid usage at protective period.
In this study, women who consulted healthcare providers when they plan to become pregnant were 6.3 times more likely to take folic acid at protective period than who did not consult. Similar to studies in Lebanon and Nigeria previous history of unsuccessful pregnancies was positively associated with intake of folic acid at protective period against NTDs [1, 25].
Data reported during the last 7 years from USA, Australia, Lebanon, Iran, United Arab Emirate and Nigeria shows folic acid usage at protective period against an NTDs range from 2.5% to 76% [1, 5, 10, 15, 25, 31, 36, 38]. The prevalence of folic acid users in this study is even lower than the least range. However, it is higher than a study done among Honduran women in 2007 which was 0.2% .
In Ethiopia, there are health facilities distributed in every city and villages in which healthcare providers deliver different medical and health need of the society including the ANC. However, folic acid usage is very low.
The poor intake of folic acid among Ethiopian women could be a result of low recommendation from policy makers, less prescription, and recommendations by healthcare providers and lack of awareness about folic acid supplements, its importance and the recommended time among women. The other one may be failures of healthcare providers to prescribe folic acid at protective time and lack of preconception care.
The study is a hospital based study on women who seek routine ANC. The result may only reflect usage among women who might have high health service seeking behavior. Another limitation of the study was it is conducted in one region, relatively a big city. So the finding of this study may not be generalized to other regions of the country, especially rural areas and small towns. Despite those limitations, the present study provides some insight into the practice of women for usage of folic acid for prevention of neural tube defects.