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Updated: Jun 13, 2025
Author Spotlight: Studying the Impact of Maternal Dietary Deficiencies on Long-Term Offspring Health Outcomes
Published on: June 28, 2024
Folic acid supplementation during preconception period in sub-Saharan African countries: A systematic review and
Mekuriaw Nibret Aweke1, Elsa Awoke Fentie2, Muluken Chanie Agimas3
1Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
Insights
Folic acid supplementation before pregnancy is low in sub-Saharan Africa, impacting maternal and infant health. Increased public health efforts are crucial to improve folic acid uptake for better birth outcomes.
Area of Science:
- Public Health
- Maternal Health
- Epidemiology
Background:
- Neural tube defects (NTDs) are severe congenital anomalies impacting the central nervous system.
- Prevalence of NTDs is higher in low- and middle-income countries, particularly in sub-Saharan Africa (SSA).
- Folic acid deficiency is a key risk factor, yet preconception supplementation research in SSA is limited.
Purpose of the Study:
- To systematically review and meta-analyze the proportion of folic acid supplementation during the preconception period in SSA.
- To identify regional variations and assess the quality of evidence regarding preconception folic acid supplementation.
Main Methods:
- Comprehensive literature search across multiple databases (EMBASE, MEDLINE, Scopus, CINAHL, Google Scholar).
- Systematic review and random-effects meta-analysis of 28 studies (12,562 participants).
- Quality assessment using Newcastle-Ottawa Scale and certainty of evidence using GRADE approach.
Main Results:
- The pooled proportion of folic acid supplementation during preconception in SSA was 14.10% (95% CI: 11.22-16.98), with significant heterogeneity.
- Highest supplementation proportions were observed in Kenya (22%) and Ghana (20%).
- Studies were generally of high quality, but the overall certainty of evidence was rated as low.
Conclusions:
- Preconception folic acid supplementation rates are critically low in SSA, despite its proven benefits for birth outcomes.
- Urgent, collaborative strategies involving healthcare organizations, governments, and policymakers are needed to enhance folic acid uptake.
- Targeted interventions are essential to improve maternal and fetal health in the region.
Introduction:
Neural tube defects (NTDs) are serious congenital anomalies of the central nervous system caused by disruptions in early embryonic development. The prevalence is about twice as common in low- and middle-income countries and more prevalent in sub-Saharan Africa. Folic acid deficiency is a major risk factor and common during pregnancy. However, limited research on preconception folic acid supplementation in this region highlights the need for systematic reviews and targeted interventions to improve maternal and fetal health.
Methods:
We conducted a systematic literature search in EMBASE, MEDLINE, Scopus, CINAHL, Google Scholar, and Google for studies on the proportion of folic acid supplementation during the preconception period, covering publications up to January 2024. Study quality was assessed using the Newcastle-Ottawa Scale. Heterogeneity was evaluated with Cochrane Q and I2 statistics, and small study effects were tested with Egger's test at a 5% significance level. The certainty of evidence was assessed using the GRADE approach. A random-effects model was used to estimate the pooled proportion of FA supplementation during the preconception period in sub-Saharan African countries.
Result:
This systematic review included 28 studies with a total of 12,562 participants. The highest (45.2%) and lowest (1.9%) proportion of folic acid supplementation during preconception period were recorded in the southern and Amhara regions of Ethiopia, respectively. The estimated pooled proportion of folic acid supplementation among women in Sub-Saharan Africa (SSA) during preconception period was (14.10%; 95% CI: 11.22-16.98) with significant heterogeneity between studies (I2 = 97.71%, p = 0.001). In sub-group analysis based on corresponding countries the highest estimated folic acid supplementation proportion during preconception period was found in studies conducted in Kenya ((22%; 95% CI: 19%-25%), I2 = 97.7%), followed by studies conducted in Ghana (20%; 95% CI: 7%-33%), I2 = 96.9%). The majority of the studies included in the analysis are of high quality, with quality scores ranging from 7 to 8. The certainty of evidence was assessed using the GRADE approach, resulting in a low overall rating.
Conclusion:
The results of this systematic review and meta-analysis indicated that folic acid supplementation during preconception period is significantly low among mothers in sub-Saharan African countries, despite being one of the best approaches to improve birth outcomes. Therefore, healthcare organizations, governments, policymakers, and other stakeholders involved in folic acid supplementation must collaborate on developing strategies to improve its uptake during the preconception period.
