Assessment of preconception folic acid use and associated factors among pregnant women in Wakiso district, Uganda: a facility based cross-sectional study

Abstract

Background: Obstetric guidelines recommend women of childbearing potential to use Folic Acid (FA) three months prior conception. Preconception FA supplementation provides adequate serum FA levels necessary for prevention of up to 72% of Neural Tube Defects (NTDs). However, majority of pregnancies in low and middle-income countries are unplanned resulting in failure to use FA as recommended. There is limited data on use of FA during the preconception period in Uganda. This study assessed preconception FA use and associated factors among pregnant women attending antenatal care (ANC) in Wakiso district. Methods: A facility based cross-sectional study was conducted from 1st June 2025 to 31st August 2025 among 943 pregnant women 15-49 years attending their first antenatal care visit at four healthcare facilities in Wakiso district (Wakiso HCIV, Kajjansi HCIV, Kasangati HCIV and Ndejje HCIV). Pregnant women were then requested to voluntarily provide written Informed consent. A structured questionnaire was used to assess use of FA prior to conception. Descriptive and Firth-logit regression analyses were performed using Stata® version 14 to characterize factors associated with preconception FA use. Analysis was stratified by pregnancy planning status. Results: The overall uptake of preconception FA use was 3% (28/943) (95% CI: 2.0-4.3%). The uptake of preconception FA use among women with planned pregnancies was 3.5% (22/631) (95% CI: 2.2-5.2) which was not statistically different from women with unplanned pregnancies [1.9% (6/312) (95% CI: 0.7-4.1)]. The mean age of study participants was 25 years (SD 5.2) with 58.4% (551/943) of the respondents attending their first ANC visit in their second trimester. Awareness about preconception FA use was 52.9% (499/943). Muslim women were more likely to use FA during the preconception period, AOR 4.05 [95% CI: 1.06 - 15.52], P value 0.041. Health workers (P=0.014) and social media (P=0.049) were significant sources of knowledge about FA. Women who were aware of the recommended start period for using FA were more likely to take FA during the preconception period (P= 0.003). Conclusion: This study found a low uptake of FA during the preconception period by Women of Reproductive Age (WRA). Lack of awareness about FA was the primary barrier for non-users. Current FA uptake is insufficient to address Uganda’s NTD burden and current health education and policy are insufficient to prevent the high burden of NTDs in Uganda. MOH needs urgent, multi-channel health education campaigns through mass media and health workers to emphasize the necessity of starting FA supplementation three months before pregnancy. Further biochemical studies to quantify actual serum FA levels among WRA and explore deeper insights into the complex behavioural determinants and socio-cultural barriers underlying the low FA uptake in Uganda is urgently needed.