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Preventive Medicine 46 (2008) 166 – 169
www.elsevier.com/locate/ypmed

Preconceptional folic acid utilization in Israel: Five years after the guidelines
Yona Amitai a,c , Nirah Fisher a,c,⁎, Hana Meiraz b,c , Nira Baram b,c ,
Marie Tounis d , Alex Leventhal c
a

Department of Maternal, Child and Adolescent Health, Ministry of Health, 20 King David St., Jerusalem 91010, Israel
b
Public Health Nursing, Ministry of Health, Jerusalem, Israel
c
The Public Health Service, Ministry of Health, Jerusalem, Israel
d
Acre District Health Office, Ministry of Health, Jerusalem, Israel
Available online 19 September 2007

Abstract
Objective. In Israel, a national survey was conducted in order to assess the efficacy of the ongoing national folic acid (FA) campaign launched in
2000. The Ministry of Health had issued official guidelines in August 2000 recommending daily FA supplementation for all childbearing age women.
Methods. In 2005, structured interviews of pregnant and postpartum women were conducted by the nursing staff of the Maternal Child Health
Clinics administered by the Public Health Service. The results of the 2005 survey are compared with similar surveys done in 2002 and 2000
(baseline).
Results. In the 2005 survey (n = 1860), FA awareness, knowledge, timing knowledge and preconceptional utilization were 90.3%, 80.8%,
74.6% and 34.0%, respectively. Education was significantly associated with compliance: only 13.6% of women with b 12 years of education
utilized FA preconceptionally versus 48.1% of women with ≥ 16 years.
In the 2002 survey (n = 1661), FA awareness, knowledge, and preconceptional utilization were 85%, 77.7% and 30.5%, respectively. In the
2000 survey (n = 1719), FA awareness was 54.6%, knowledge was 17.6% and preconceptional utilization was 5.2%.
Conclusions. The national preconceptional FA campaign in Israel has resulted in significant increases in awareness, knowledge and
preconceptional utilization.
© 2007 Elsevier Inc. All rights reserved.
Keywords: F; olic acid; Preconceptional health; Neural tube defects; National survey; Israel

Introduction
Conclusive evidence that perceptional folic acid (FA) is
essential in the prevention of neural tube defects (NTDs) has
been available since 1991 (MRC, 1991). In 1999, Berry et al.
provided irrefutable evidence that confirmed the efficacy of a
400 μg daily dose.
Terminations of pregnancy as a result of improved prenatal
diagnostics have led to a decreased incidence of NTDs at birth.
In order to ascertain the “true” incidence of NTDs the Ministry of
Health's (MOH) Department of Community Genetics established an “NTD” registry in Israel in 1999. Reports from
⁎ Corresponding author. Department of Maternal Child and Adolescent
Health, Ministry of Health, 20 King David St., Jerusalem 91010, Israel. Fax:
+972 2 6228907.
E-mail address: nirah.fisher@moh.health.gov.il (N. Fisher).
0091-7435/$ - see front matter © 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ypmed.2007.09.005

ultrasound clinics, genetic laboratories and units, and pathology
departments are cross-referenced with the national birth registry,
stillbirth and abortion (spontaneous and induced) records.
The rate of NTDs in 1999–2000 was 1.2 per 1000 in the
Jewish population and 2.2 per 1000 live births in the Arab
population. Live-born, stillborn infants and electively terminated pregnancies were included in the analyses. The incidence of
spina bifida (reflected within NTDs) was 0.49/1000 Jews and
0.98/1000 Arab live births (Zlotogora et al., 2006).
A baseline national survey conducted in June 2000 (n = 1719)
revealed FA awareness, knowledge and preconceptional utilization at 54.6%, 17.6% and 5.2%, respectively. Survey results
endorsed the need for a national FA policy.
In August 2000, guidelines were issued recommending a
daily 400 μg FA supplement for all women in their childbearing
years with emphasis on the 3 months preceding conception and
throughout the first trimester (MOH, 2000). National guidelines

Y. Amitai et al. / Preventive Medicine 46 (2008) 166–169

167

A total of 2256 Hebrew and Arabic multiple-choice questionnaires were
distributed via district health offices to 515 MCHCs throughout the country.
Nurses conducted structured interviews on the first 3–5 eligible women who
presented at the MCHC during the survey period.
Awareness, knowledge of FA, timing knowledge and utilization, were used
as dependent variables. Awareness was defined as ever having heard of FA.
Knowledge of FA was defined as knowing that “FA prevents a number of birth
defects”. Timing knowledge was defined as knowing that, “FA should be taken
preconceptionally and throughout the pregnancy”. Utilizing FA preconceptionally on a regular basis was defined as having taken FA; “at least 4 days a week”
in the month preceding the current pregnancy. Women were asked to delineate
the source of their FA information. Also, women were asked when they began
prenatal care and whether they had taken FA prenatally.
Religion, age, education, parity and sources of information were used as the
main independent variables. Education was defined by years of schooling. Parity
for pregnant women was adjusted upward in order to reflect the current pregnancy.
Statistical analysis was performed using SPSS 13. Regression analysis
incorporated the Hosmer and Lemeshow test for best fit model. Confidence
intervals were computed at the 95% level.

for a 4 mg preconceptional FA supplement to prevent NTD
recurrence have been in effect since 1994 (MOH, 1994).
A national FA campaign was launched concurrently with the
issue of the 2000 guidelines. A detailed description of the
original campaign was reported earlier (Amitai et al., 2004).
In 2002, the first post campaign survey was conducted
(n = 1661). Folic acid awareness, knowledge and preconceptional utilization were 85%, 77.7% and 30.5% (Jewish 35%,
Arabs 21%), respectively (Amitai et al., 2004).
Data from the NTD registry (2002–2004) reported a
concurrent decline in open NTDs (Jews 33%, Arabs 23%)
and spina bifida (Jews 45%, Arabs 35%; Zlotogora et al., 2006).
As a result of the 2002 survey, we began targeting specific
populations at risk for NTDs. Southern district Bedouin have a
high fertility rate (7–8) and the highest incidence of NTDs (3/
1000) (Friedlander, 2002; Zlotogora et al., 2002). Programs
targeting this population were developed in conjunction with
Ben Gurion University. Bedouin women were trained as health
educators and employed in various outreach programs.
Ultra orthodox Jews in the Tel Aviv district were targeted due
to their high fertility rate (7.0) (Friedlander, 2002) and religious
objections to terminations of pregnancy despite congenital defects. Programs were developed in conjunction with the approval
of local rabbis. A nurse functioned as the FA liaison with local
existing women's groups; providing lectures and handouts and
weekly rounds at the postpartum convalescent facility.
An annual national FA awareness week was established in
January 2005. The week is highlighted by intensive radio advertisements and the distribution of FA pamphlets to all women in their
childbearing years by sick fund and drugstore pharmacists. During
each of these weeks a total of 125,000 pamphlets were distributed
(live births in Israel per annum are 143,000).
The focus of this report is the March 2005, third national FA
survey.

Results
A total of 1860/2256 (82.4%) questionnaires were returned.
Demographic data are presented in the Table 1.
Religion was classified as Jewish, Moslem Arab (excluding
Bedouin), Bedouin, Christian Arab, Druze and other. Religion
was delineated by 1830 respondents (1123 Jewish and 707 Arab
women).
Moslem Bedouin women had significantly more children and
less years of schooling than Druze, Christian and non-Bedouin
Moslem women. Christian women had significantly more years
of schooling than Moslem and Bedouin Moslem women.
There was no significant difference between the four Arab subpopulations in FA awareness, knowledge, timing knowledge and
utilization. The four groups, given the small individual numbers,
were therefore combined into one and referred to as Arab (Table 1).
FA awareness, knowledge, timing and utilization

Methods

In the 2005 survey, FA awareness, knowledge, timing
knowledge and preconceptional utilization were 90.3%, 80.8%,
74.4% and 34.0%, respectively (Table 1). A subset of 61 (3.3%)

Pregnant and women up to 2 months postpartum who presented to the
MCHCs (Maternal Child Health Clinics) for either prenatal, postpartum or infant
care were the target population.

Table 1
2005: Selected sociodemographic characteristics of women, folic acid awareness, knowledge, timing knowledge, preconceptional and prenatal utilization as defined by
religion in Israel
Arab

N (%)
Age a, mean (SD)
Children a, mean (SD)
Education a, mean (SD)
Awareness (%)
Knowledge a (%)
Timing (%)
Utilization (%)
Prenatal utilization (%)

Moslem NonBedouin

Moslem
Bedouin

Christian

Druze

P

450 (24.2)
27.0 (5.3)
2.6 (1.5)
12.4 (2.7)
82.0
80.6
68.6
25.6
73.8

90 (4.8)
27.0 (5.1)
3.2 (2.2)
10.4 (4.5)
78.7
75.0
61.1
27.8
71.6

84 (4.5)
28.4 (5.0)
1.8 (.9)
13.7 (2.3)
89.3
72.7
68.8
26.2
81.0

83 (4.5)
27.7 (5.4)
2.4 (1.4)
12.8 (3.2)
81.9
30.1
71.2
30.1
76.0

b0.001⁎⁎⁎
b0.001⁎⁎⁎
b0.001⁎⁎⁎
0.298
0.374
0.572
0.845
0.152

Arab

Jewish a

707 (38.6)
27.3 (5.2)
2.5 (1.6)
12.4 (3.1)
82.8
77.6
67.6
26.4
74.9

1123 (61.4)
29.2 (5.0)
2.3 (1.7)
14.0 (3.9)
95.2
82.6
78.3
39
79.0

Arab to Jewish,
P

b0.001⁎⁎⁎
0.008⁎⁎
b0.001⁎⁎⁎
b0.001⁎⁎⁎
0.013⁎
b0.001⁎⁎⁎
b0.001⁎⁎⁎
0.048⁎

Total: Arabs and Jews

1830
28.5 (5.2)
2.4 (1.6)
13.4 (3.7)
90.3
80.8
74.4
34.0
77.4

a
Jewish women were significantly: older than Arab women, had less children, more years of education, increased FA awareness, knowledge, timing and
preconceptional utilization.

168

Y. Amitai et al. / Preventive Medicine 46 (2008) 166–169

women had utilized FA preconceptionally, but only 1–3 days a
week.
Since 2002, the first survey in which religion was recorded;
the Arab population has exhibited significant gains in FA
awareness, knowledge and utilization respectively, from 73.5%,
66.8%, 21.5% in 2002 to 82.8%, 77.6% and 26.4%, respectively,
in 2005. An increase in FA awareness and utilization from 91.0%
and 34.8% in 2002, to 95.2% and 39.0%, respectively, in 2005
was also observed among Jewish women.
Jewish and Arab populations differed significantly in their
age, number of children, years of schooling and FA awareness,
knowledge, timing and utilization (Table 1).

(P b 0.0001, OR = 5.64, CI: 4.0–8.05) and knowledge
(P = 0.0002, OR = 2.0, CI: 1.4–2.8).
Information sources and FA utilization

A majority of the women in our current survey (87.2%) had
at least 12 years of education and 24.9% had completed 16 or
more years. Awareness, knowledge, timing and utilization
increased significantly and were all correlated with years of
education (P b 0.001) (Fig. 1). The primary factor associated
with FA timing was having at least 12 years of education
(P b 0.001, OR = 6.46, CI: 4.2–9.9).

Two sources of information that were significantly related to
utilization were the internet (P b 0.0001, OR = 2.4, CI: 1.6–3.5)
and the physician (P b 0.0001, OR = 2.2, CI: 1.8–2.8).
The internet was cited by relatively few women [n = 140
(8.3%)] as an information source. This group however had the
highest rates of FA knowledge (P = 0.005, OR = 3.4, CI: 1.5–
8.0), timing (P = 0.002, OR = 2.6, CI: 1.4–5.0) and preconceptional utilization (P b 0.001, OR = 2.9, CI: 1.9–4.3).
The physician (66.6%) and nurse (49.9%) were the major
sources of information among women who utilized FA preconceptionally. For Arab women the nurse had been the primary
source of information (75.3%), while for Jewish women it was the
physician (72.2%). Physicians, as a source of information correlated with FA timing (P = 0.001, OR = 1.5, CI = 1.2–1.9) and
preconceptional utilization (P b 0.001, OR = 2.13, CI: 1.7–2.7),
though not with knowledge (P = 0.224, OR = 1.2, CI: 0.9–1.6).
Nurse counseling was associated with knowledge (P b 0.001,
OR = 1.8, CI: 1.3–2.4).

Age

Prenatal FA utilization

Age was not significantly associated with any FA variable in
the 2005 survey,

Prenatal FA utilization at any stage was 77.4%. In addition to
the women who had utilized preconceptional FA, 206 (11.1%)
women began their prenatal FA by or before 6 weeks gestation.

Factors associated with awareness, knowledge, timing and
utilization education

Correlation between folic acid awareness, knowledge
and utilization

Discussion

Women who did not take FA preconceptionally were
overwhelmingly (90.3%) unaware of the correct timing and
84.9% did not know that FA prevents birth defects.
The primary correlates associated with FA preconceptional
utilization as determined by the best fitting model using the
Hosmer and Lemeshow test (sig = 0.966) were FA timing

Five years into the national FA campaign; preconceptional
utilization has increased from 5.2% (2000) to 34% (2005),
awareness has exceeded 90%, more than 80% know that FA is
essential in the prevention of birth defects and more than 70%
know that in order to be effective FA must be taken preconceptionally as well as during the pregnancy.

Fig. 1. Folic acid awareness, knwoledge, timing and utilization in Israel: as determined by years of education (2005).

Y. Amitai et al. / Preventive Medicine 46 (2008) 166–169

Education is significantly correlated with FA utilization. To
achieve client empowerment, it is necessary to provide the
knowledge that can influence attitudes and impact on behavior.
Women must know not only that FA prevents birth defects but that
it must be taken preconceptionally. In the present study, timing
was a stronger indicator of preconceptional utilization than simply
knowledge of the benefits, and logically so, since timing is the
essential component of preconceptional compliance. “Providing
knowledge can only reap the fruit of compliance in a society where
governments, private interests, and other sectors work together to
support individuals making healthy choices” proclaims the WHO,
1986 Ottawa Charter for Health Promotion. Ideally, MCHCs and
pharmacies should be local, accessible and run culturally sensitive
community outreach programs. Supportive environments, access
to information, life skills and opportunities for making healthy
choices are the building blocks that can empower women to
achieve their fullest health potential (WHO, 2005).
Prenatal FA compliance in Israel was over 75%. This
indicates a positive attitude towards vitamins and a population
willing to comply with health messages. Once women are part
of the health system, the system is effective, across the board in
communicating the message. The ideal then would be to convert
the entire health system and not just the prenatal system into a
“preconceptional” health system that advocates ongoing health
promotion and FA utilization throughout the childbearing years.
Preconceptional health is part of general health promotion. A
woman's health status before her pregnancy is a major determinant of the outcome of her pregnancy, the health of her newborn, and her own long-term prognosis.
The wide gap between FA knowledge and utilization is a
common finding in many countries. As a general rule, patients
tend to comply better with curative treatment for actual disease,
than with preventive treatment for potential conditions. Approximately 50% of pregnancies are unplanned which makes achieving
a high preconceptional FA utilization rate even more challenging.
All providers who routinely interact with women, including
general practitioners, nurses, pharmacists, phlebotomists, gynecologists, pharmacists and pediatricians should be enrolled in
the endeavor. Every birth control consultation is a potential birth
and every childhood immunization is an opportunity for
parental health education.
Limitations
The questionnaire was not anonymous and might have led to
over-reporting compliance; however, the same technique has

169

been used in all 3 surveys and, therefore, any increment is
probably real and not an artifact.
Acknowledgments
We would like to thank the Tipat Halav (MCHCs) nurses
throughout the country who have been instrumental in spreading
the FA message and interviewing the study women. A special
thank you to the following nurse supervisors for their role in
organizing the distribution of the survey questionnaire: Shula
Altman, Yael Arbelli, Bracha Avraham, Chana Ben-Ari, Sara
Binyamin, Yardena Ben-Chamu, Gila Benztik, Zahava Dror,
Naomi Eidelstein, Sara Hadar, Tzipi Kachal, Dorit Mizrachi,
Yehudit Pasternak, Miriam Payis, Leora Shachar, Gila Stern,
Tova Stern, Liora Vasterman, Ilana Yaacobi. In addition, we
would like to acknowledge Professor Joel Zlotogora as the
source of all our NTDs data, and thank him for his inspiration
and guidance.
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