Health Fact Sheets
Folic acid-containing supplement use among Canadian-born and immigrant women aged 15 to 55 years, 2015 to 2018, 2021
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Summary
- Folic acid plays a vital role in preventing birth defects in babies. The benefits of taking folic acid are greatest in the early weeks of pregnancy, before many women know they are pregnant.
- The proportion of folic acid-containing supplement usersNote 1 was generally low among women of reproductive age (15-55) in Canada. Approximately 1 in 5 Canadian-born women and 1 in 4 immigrant women reported using folic acid-containing supplement at the time of survey.
- Among women who had a recent birth, almost 7 in 10 Canadian-born women used a folic acid-containing supplement before pregnancy, in comparison to 1 in 2 immigrant women from West Asia, Central Asia, and the Middle East.Note 2
- Awareness of the benefits of folic acid in preventing birth defects is the strongest factor associated with folic-containing supplement use before and during pregnancy.Note 3
- A lower proportion of immigrant women who had a recent birth (65.2%) were aware that folic acid prevents birth defects compared to Canadian-born women (80.8%).Note 4
- Divergence in awareness of the benefits of folic acid exists within the immigrant population. Among immigrant women from Northern Europe, 94.4% were aware of the link between folic acid and birth defects, in contrast to 43.8% of those from Southern Europe.
Background
Folic acid is a B vitamin that supports the closure of the neural tube which becomes a baby’s spinal cord and brain. If the neural tube does not close properly during the early weeks of pregnancy, it results in spine, brain and skull defects that can lead to neural tube defects (NTDs), such as spina bifida or anencephaly.Note 5
Folate can be found in many foods, including dark leafy green vegetables, citrus fruits, and beans. To increase the level of daily folic acid intake, the Government of Canada has required that folic acid be added to staple foods since 1998. These staple foods include wheat flour, enriched pasta, and cornmeal products. However, diet alone does not ensure that women of reproductive age meet the recommended daily intake of folic acid.
To reduce the risk of birth defects, it is recommended that all women who could become pregnant or are pregnant take a multivitamin containing 400 µg of folic acid per day, in addition to a balanced diet.Note 5 In total, the maximum amount of folic acid supplementation should not exceed 1000 µg, unless directed by a health care provider.
Who is impacted?
Between 2006 and 2020, 2,162 newborns were affected by NTDs (4 per 10,000 total births).Note 6 Many of these cases could be prevented by folic acid supplementation during early pregnancy. Folic acid-containing supplement use is the most important factor associated with red blood cell folate concentrations, an indicator of folate status, in Canadian women of reproductive age.Note 7 However, only 1 in 5 women of reproductive age in Canada have adequate intake of folic acid for NTD risk reduction.Note 8
In Canada, approximately 1 in 3 babies were born to immigrant mothers and certain racialized groups have higher fertility rates.Note 9Note 10 Immigrant women in Canada are less likely to take a daily multivitamin supplement containing 400 µg folic acid during the key periods for the prevention of NTDs and have lower awareness of the benefits of folic acid.Note 11Note 12 Immigrant women’s lower awareness of the benefits of folic acid and slightly higher fertility rates could potentially translate into a higher prevalence of NTDs.
Folic acid-containing supplement use among immigrant women of reproductive age: Diverse population, varied levels of use
All groups of women would benefit from better adherence to Canadian guidelines on folic acid supplementation. Folic acid-containing supplement use is generally low among women of reproductive age in Canada. Among women of reproductive age (including both pregnant and non-pregnant), a lower proportion of those born in Canada reported using a folic acid-containing supplement at the time of the surveyNote 1 (19.0%) compared to immigrant women overall (23.2%). Compared to Canadian-born women, the proportion of folic acid-containing supplement use was higher among immigrant women from several regions, including Southern Asia (26.9%), North America excluding Canada (26.3%), West Central Asia and the Middle East (25.8%), Eastern Asia (25.2%), Eastern Europe (23.9%), and Africa (23.8%) (Chart 1).
Data table for Chart 1
| Percent | 95% confidence interval | ||
|---|---|---|---|
| lower | upper | ||
|
|||
| Ref. | |||
| Canadian-born women | 19.0 | 18.5 | 19.5 |
| Region of birth | |||
| Western Europe | 16.8 | 13.0 | 21.1 |
| Eastern Europe | 23.9 | 19.7 | 28.6 |
| Northern Europe | 17.3 | 13.3 | 21.9 |
| Southern Europe | 13.8 | 9.2 | 19.7 E use with caution |
| North Am excl. CA | 26.3 | 20.5 | 32.6 |
| Caribbean & South & Central Am | 21.1 | 18.0 | 24.4 |
| Africa | 23.8 | 20.3 | 27.6 |
| West Central Asia and the Mid-East | 25.8 | 21.8 | 30.1 |
| Eastern Asia | 25.2 | 22.3 | 28.3 |
| Southeast Asia | 18.9 | 15.9 | 22.1 |
| Southern Asia | 26.9 | 23.7 | 30.4 |
| Other | 18.4 | 14.9 | 22.4 |
Proportion of folic acid supplementation before pregnancy was lower among those from West Asia, Central Asia, and the Middle East compared to Canadian-born women
Among women aged 15 to 55 years who gave birth within the past five years, proportion of folic acid supplementation before pregnancy was generally low. The proportion of women who used folic acid-containing supplements three months before pregnancy were similar among immigrant women (61.4%) and Canadian-born women (65.7%). However, compared to Canadian-born women, folic acid-containing supplement use before pregnancy was lower among immigrant women from specific regions, namely West Asia, Central Asia, and the Middle East (50.0%), while immigrant women from other regions had similar proportions (Chart 2).
Among all groups of immigrant women who took a multivitamin containing folic acid before pregnancy, the majority of them took it every day or almost every day (>94%), a level that was similar to that of Canadian-born women (98.6%).
Data table for Chart 2
| Percent | 95% confidence interval | ||
|---|---|---|---|
| lower | upper | ||
|
|||
| Ref. | |||
| Canadian-born women | 65.7 | 64.3 | 67.2 |
| Region of birth | |||
| Western Europe | 66.1 | 50.7 | 79.3 |
| Eastern Europe | 67.7 | 55.5 | 78.3 |
| Northern Europe | 80.4 | 66.8 | 90.2 |
| Southern Europe | 39.3 | 17.5 | 64.9 E use with caution |
| North Am excl. CA | 71.8 | 58.7 | 82.6 |
| Caribbean & South & Central Am | 60.7 | 52.1 | 68.7 |
| Africa | 59.4 | 52.4 | 66.0 |
| West Central Asia and the Mid-East | 50.0 | 40.1 | 59.9 |
| Eastern Asia | 69.4 | 62.1 | 76.1 |
| Southeast Asia | 58.8 | 50.0 | 67.1 |
| Southern Asia | 61.1 | 53.1 | 68.6 |
| Other | 65.5 | 53.9 | 75.8 |
Proportion of folic acid supplementation during pregnancy was higher among immigrant women from Northern Europe and lower among those from Africa, compared to Canadian-born women
A majority of women aged 15 to 55 years who gave birth within the past five years were folic-acid containing supplement users. The proportion of women who used folic acid-containing supplements during the first three months of pregnancy was lower among immigrant women overall (86.7%), compared to Canadian-born women (91.4%).
The proportion of those who used a folic acid-containing supplement during the first three months of pregnancy was higher among immigrant women from Northern Europe (98.4%) and lower among those from Africa (80.1%), compared to Canadian-born women (91.4%) (Chart 3).
Among all groups of immigrant women who took a multivitamin containing folic acid in the first three months of pregnancy, the majority took it every day or almost every day (>98%), a level similar to that of Canadian-born women (98.5%).
Data table for Chart 3
| Percent | 95% confidence interval | ||
|---|---|---|---|
| lower | upper | ||
| Source: Canadian Community Health Survey, 2015-2018, 2021. | |||
| Ref. | |||
| Canadian-born women | 91.4 | 90.4 | 92.3 |
| Region of birth | |||
| Western Europe | 88.3 | 75.0 | 96.0 |
| Eastern Europe | 93.5 | 87.2 | 97.3 |
| Northern Europe | 98.4 | 94.5 | 99.8 |
| Southern Europe | 89.5 | 63.3 | 99.1 |
| North Am excl. CA | 91.8 | 82.4 | 97.1 |
| Caribbean & South & Central Am | 85.9 | 80.2 | 90.5 |
| Africa | 80.1 | 73.7 | 85.6 |
| West Central Asia and the Mid-East | 86.1 | 76.1 | 93.1 |
| Eastern Asia | 91.6 | 85.8 | 95.6 |
| Southeast Asia | 85.5 | 75.5 | 92.5 |
| Southern Asia | 85.4 | 78.6 | 90.7 |
| Other | 91.7 | 85.1 | 96.0 |
A recent studyNote 3 based on the Canadian Community Health Survey also indicated that a lower proportion of recent and non-recent immigrants reported using folic acid-containing supplement in the first three months of pregnancy compared to Canadian-born women. Furthermore, this pattern persisted after considering socioeconomic status, lifestyle factors, and awareness of the link between folic acid and birth defects in the logistic regression model.Note 3
Awareness of the benefits of folic acid in preventing birth defects was lower among immigrant women from most regions, compared to Canadian-born women
Awareness of the benefits of folic acid for preventing birth defects is the strongest factor associated with folic acid-containing supplement use before and during pregnancy.Note 3 However, awareness was lower among immigrant women (65.2%) compared to Canadian-born women (80.8%). Among immigrant women, awareness differed by region of birth. Compared to Canadian-born women, awareness of the benefits of folic acid in preventing birth defects was higher among immigrant women from Northern Europe (94.4%), while the following regions had lower awareness: Eastern Asia (72.2%), South, Central America, and the Caribbean (65.4%), West Central Asia and the Middle East (65.2%), Southeast Asia (61.2%), Southern Asia (57.9%), Africa (56.9%), and Southern Europe (43.8%) (Chart 4).
Data table for Chart 4
| Percent | 95% confidence interval | ||
|---|---|---|---|
| lower | upper | ||
|
|||
| Ref. | |||
| Canadian-born women | 80.8 | 79.5 | 82.1 |
| Region of birth | |||
| Western Europe | 84.2 | 75.8 | 90.6 |
| Eastern Europe | 81.0 | 70.0 | 89.4 |
| Northern Europe | 94.4 | 84.3 | 98.8 |
| Southern Europe | 43.8 | 20.7 | 69.0 E use with caution |
| North Am excl. CA | 83.5 | 71.0 | 92.2 |
| Caribbean & South & Central Am | 65.4 | 56.9 | 73.2 |
| Africa | 56.9 | 50.0 | 63.6 |
| West Central Asia and the Mid-East | 65.2 | 55.2 | 74.3 |
| Eastern Asia | 72.2 | 64.0 | 79.4 |
| Southeast Asia | 61.2 | 52.2 | 69.7 |
| Southern Asia | 57.9 | 49.5 | 66.0 |
| Other | 76.6 | 65.9 | 85.2 |
Data sources
The proportion of women aged 15 to 55 years who used a folic acid-containing supplement was estimated based on combined data from the Canadian Community Health Survey (CCHS) 2015-2018, and 2021, where the Maternal Experience Module was available. The pooled estimates do not represent the population of any given CCHS cycle, since the samples were drawn from an evolving population. Estimates in this article excluded the institutionalized populationNote 13 and the territories because the coverage of CCHS in 2021 does not represent the entire population of the territories.Note 14 Survey questions on folic acid-containing supplement use could be found here: Canadian Community Health Survey- 2015; CCHS - 2016; CCHS-2017; CCHS-2018; CCHS-2021.
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