Background
Benefits of positive nutritional interventions can be maximised before conception and during the first 12 weeks of pregnancy [
1]. Three individual components that influence an individual’s susceptibility to later life disease include genome, lifestyle and early life development in and ex utero [
2]. The thrifty phenotype hypothesis states that nutrition in utero plays an important part in the relationship between early growth and later development of the signs of metabolic syndrome [
3]. Deficient maternal diet or placental problems can cause stress to the foetus prompting adaptations to increase chance of survival [
2‐
6]. Adaptations include protecting vital organs such as the brain whilst the development of other systems such as the endocrine system may be compromised [
6]. Biological organ and tissue changes which are not apparent at birth may give rise to future health problems. Poor nutrition in vitro can optimise metabolic efficiency and storage for an expected birth environment that will also be nutritionally deprived [
6]. Adaptations have a more pronounced detrimental effect when in and ex utero environments do not match. For example, there is evidence of high rates of glucose intolerance in low birth weight individuals that become overweight in early life [
3] but low rates of diabetes when there is matching chronic malnutrition both in and ex utero [
7,
8].
There is increasing evidence linking inadequate nutrition and deficiency of nutrients during pregnancy with later life obesity [
9], cardiovascular disease (CVD) [
10], type 2 diabetes (T2DM) and atopic diseases [
11]. Obese or diabetic mothers have a higher leptin resistance resulting in decreased satiety and overweight offspring or low birth weight offspring whose accelerated post-natal growth is associated with a greater risk for CVD [
10‐
13]. Higher maternal glycemic diets result in higher birth weights and skin thickness in offspring. Maternal glucose levels have a linear relationship with macrosomia and increased adiposity in offspring [
9]. Maternal obesity can result in developmental programming due to DNA methylation of sperm to alter gene expression causing a ‘fuel mediated teratogenesis’ resulting in a general increase in obesity and T2DM in successive generations [
9,
13]. Low birth weight offspring have a greater chance of future T2DM development [
3,
4,
12,
14], whilst higher birth weights showed increase risk of type 1 diabetes (T1DM) [
15].
The National Institute of Health and Care Excellence (NICE) guidelines recommend that pregnant women and women planning to conceive should take supplements of folic acid [
16]. Not taking folic acid before and during pregnancy increases the risk of offspring which are small for gestational age (SGA) [
17]. Folic acid, 400μg, is recommended daily, starting at least 1 month before pregnancy and during the first 3 months [
16]. There is concern about patient adherence on following advice on folic acid supplementation [
18]. Women are advised to take a 5 mg/day supplement of folic acid if: they have previously had a baby with a neural tube defect; if they or their partner have a neural tube defect or a family history of neural tube defects; or if the woman has diabetes or takes anti-epileptic medication and other named conditions [
1].
NICE also recommends a daily Vitamin D 400 IU supplement to mothers that have not taken Vitamin D supplements during pregnancy [
19], exclusively breast fed infants or formula-fed infants receiving less than 500 ml daily, infants and children from 6 months to 5 years and to women who are pregnant and breastfeeding [
16,
20,
21]. A systematic review of 42 studies revealed that Vitamin D deficiency measured by food intake during pregnancy causes an increased occurrence of childhood asthma and wheeziness [
11]. However, a smaller study (
n = 500) correlated an increase in asthma and atopic eczema with higher vitamin D serum concentrations [
22]. Vitamin D deficiency may be implicated with an increased risk of gestational diabetes, pre-eclampsia [
23], osteoporosis, diabetes and some cancers [
21]. The mother’s level of vitamin D during pregnancy largely determines the offspring’s vitamin D status [
24]. Low Vitamin D is defined as having a plasma concentration of below 25 nm/litre (10 ng/ml) [
25]. Symptomatic Vitamin D deficiency is common in children under 5 years old with an occurrence of 7.5 per 100,000 children [
26]. Children born to mothers with serum 25-(OH)-D concentration < 50 nmol/L during pregnancy exhibit deficits in bone mineral content at 9 years of age [
21].
Healthy Start is a UK government scheme that acts as a nutritional safety net for pregnant women that are currently at least 10 weeks pregnant and families or have a child from 6 months to less than 4 years old and on qualifying benefits and tax credits [
27,
28]. Studies have found that the uptake of Healthy Start vitamins ranged between 3 and 10% [
29], whilst the uptake of Healthy Start food and milk vouchers were reported to be between 72 to 86% [
30,
31]. This difference could exist due to availability of milk and food from a wide variety of outlets. Some studies propose that the uptake of Healthy Start vitamins can be increased to 23% for adults and 20% for children if universal free supplementation was supported by a campaign to increase awareness [
31].
A systematic review of internet usage of pregnant women seeking pregnancy related information has reported that women use the internet as a source of information at least once a month with fetal development and nutrition in pregnancy being the most frequent search criteria [
32]. Women found the information on the internet to be reliable and useful. However, women did not always discuss the information sourced from the internet with their health providers and this could result potentially in unreliable information leading to inaccurate beliefs e.g. “Eating for two” whilst pregnant. Another systematic review reported that motivational interviewing in brief consultations with healthcare professionals can offer a moderate advantage to changing behaviour as compared to using non-human information sources e.g. leaflets [
33].
The potential of long term effects caused by poor nutrition, lack of vitamin D and folic acid supplementation, together with the low uptake rate of the Healthy Start vitamin supplements was the impetus behind our investigations. The aim of the study was to investigate women’s expectations, knowledge, behaviour, information sources and identify any gap between expectations and level of satisfaction on advice received about nutrition and vitamin supplementation before and during pregnancy.
Discussion
This study revealed women’s information sources, behaviour, expectations, knowledge and level of satisfaction concerning advice about good nutrition and recommended supplements before and during pregnancy. Making healthy dietary changes and taking the recommended vitamin supplements especially before conception and during the first 12 weeks of pregnancy has the potential to maximise health benefits for the offspring.
Women looked more for information from electronic sources e.g. the internet than healthcare professionals both before and during pregnancy. This preference for using electronic media as an information source before pregnancy is a shared outcome found in systematic reviews of similar studies [
32]. Women who sourced information on the internet showed a statistically significant correlation with taking folic acid (
p = 0.006), vitamin D (
p = 0.004) and increasing dietary intake of fresh fruits and vegetables (
p = 0.017) before pregnancy. However, the internet may provide information not supported by NICE guidelines resulting in mistaken beliefs e.g. “Eating for two” whilst pregnant and taking supplements that are not recommended. During this study (March 2015), the NHS website recommended folic acid but did not recommend Vitamin D, it has since been updated [
38]. There is an opportunity for healthcare professionals to direct women to credible electronic information sources. Women were interested in using mobile applications as electronic sources of information (27%,
n = 36). Validated mobile applications can deliver recommended information in timely meaningful ‘digestible’ pieces and have the potential to remind and update mothers of the latest nutritional guidance and antenatal tests, preventing confusion from conflicting information through an enhanced user experience [
39,
40].
During pregnancy women had the opportunity to speak to healthcare professionals e.g. at antenatal clinics, therefore there was an increase in women obtaining information from these sources as well as an increase from electronic sources. Healthcare professionals were the information source women most desired to access during pregnancy. This is a shared outcome with a systematic review of similar studies [
33]. Healthcare professionals, with the exception of pharmacists, are not easily accessible to women who are planning pregnancy. The inclusion of a dietitian in the antenatal team has been suggested [
41]. A dietitian who routinely engages with all women early on in pregnancy would enable the provision of targeted information concerning nutrition and supplements. However, encouraging healthcare professionals to act as an information source before pregnancy may enable more women to have the opportunity of benefiting from good nutrition and the recommended supplements at an optimal time, rather than waiting for the first antenatal clinic appointment when it is too late to start taking folic acid.
Women expected to receive advice both on nutrition and nutritional supplementation from healthcare professionals. Women also stated that their knowledge of nutrition and nutritional supplements was adequate and they were satisfied with the advice they received on nutrition and supplements. However, the statistically significant difference in the use of folic acid (
p = 0.007), vitamin D and folic acid combination (
p = 0.004), and commercial branded pregnancy supplements (
p < 0.001) shows that women took more of these supplements during pregnancy than before. Although women felt that their knowledge was adequate and were satisfied with the advice received, they did not take folic acid before pregnancy or vitamin D as recommended in the NICE guidelines. In comparison, a study in Ireland found that over 57% of pregnant women did not take folic acid before pregnancy, with 35% not knowing that this was recommended but, 96% took folic acid during early pregnancy [
42]. Interestingly, only 11% of women in our study stated that folic acid advice was given too late. This highlights a ‘gap’ between the women’s expectations and the desired clinical outcomes.
Some women were not advised as to the reason to take folic acid and vitamin D. It is important that women are provided with the rationale for taking each supplement. Providing such explanations and involving individuals in healthcare decisions is recommended by NICE to help adherence [
43]. Communication with healthcare care professionals before pregnancy could ensure that a consistent message is provided and allow for questions and discussion. The timing and the explanation of nutritional information is important to the health of both mother and baby. Women are not being educated to know what supplements they should take and when they should start them. Provision of timely, trusted and correct advice would help in preventing any confusion which may arise from using different information sources and may reduce queries during midwife and GP appointments. The antenatal clinic ‘booking in’ appointment (at approximately 10 weeks) is too late in pregnancy to start taking folic acid, but this is often women’s first contact with the antenatal clinic. Previous pregnancy did not result in women taking folic acid (
p = 0.477), Vitamin D and folic acid combination (
p = 0.522), Healthy Start vitamins (
p = 0.787) or commercially branded pregnancy vitamins (
p = 0.604) before their next pregnancy. This indicates that women had not retained the information they should have received in earlier pregnancies.
The high uptake of commercially branded vitamins during pregnancy were encouraged by its free provision at the antenatal booking-in appointment. Women will take supplements if they are provided free under the endorsement of a health care professional. The low uptake of the Healthy Start vitamin scheme is a missed opportunity to provide free vitamins to women.
Women desired to use community pharmacists as an information source, yet during pregnancy, few reported asking a community pharmacist for information. Interestingly, pharmacies (
n = 63) represented the most frequented location for obtaining vitamins, but the lowest resource accessed for verbal (
n = 3) and leaflet advice (
n = 1) by women. Women may not be aware of community pharmacist’s ability to provide information on nutrition and supplements for pregnancy [
44]. Community pharmacists are an accessible source of information and need to proactively advertise their nutritional competency, especially in relation to promoting the importance of healthy nutrition and supplements before pregnancy. Community pharmacies should promote the uptake of cost-effective pregnancy vitamins e.g. Healthy Start vitamins [
45]. Community pharmacists have great potential to be an excellent information source for women who are planning to become, or who are pregnant and should encourage women to enroll on the Healthy Start scheme if they are eligible. Community pharmacists could help in ensuring that information given to women is in accordance with current guidelines. e.g. starting folic acid at least 1 month before pregnancy and continuing for 3 months after and discussing the role of folic acid to prevent neural tubular defects and SGA.
Healthcare professionals did not always check women’s adherence to taking supplements with 20% of women not being asked if they were continuing to take folic acid and 56% not asked if they were taking vitamin D. Healthcare professionals need to question women to confirm supplementation and this should be part of their checklist.
Even though electronic sources are popular information resources for pregnant women, existing internet sites and mobile application were unable to adequately educate and motivate women to take the required supplements before pregnancy nor inform them of Healthy Start Vitamins. Women have reported a desire to talk to healthcare professionals e.g. antenatal clinic nurses and community pharmacists. This is a shared outcome with an Australian study, which reported that advice from healthcare professionals was regarded as the most reliable by women [
33]. Systematic reviews state that motivational interviewing by such healthcare professionals can offer a moderate advantage in helping change behavior when compared with information only sources e.g. internet and mobile applications [
33]. Women also statistically significantly desired mobile applications as the most preferred electronic source of information (
p = 0.012). A mobile application for childbearing age women that allows direct contact with healthcare professionals may be a way forward to encourage women to eat healthily and take folic acid before conception and during pregnancy. The researchers have not found mobile applications that offer this feature to support pregnant women in the UK during the study period.
Limitations
The study was conducted in the period from February 23rd to March 5th 2015 and is reflective of this environment at that point in time. This study focused on pregnant women knowledge and behaviour with regards to supplements, therefore the important issues involved in pregnancy for overweight women or overeating in pregnancy were not examined in this study. The sample size is small and constituted only of women who attended the antenatal clinic at CUH and thus results may not be representative of other locations. Furthermore, the questionnaire for this study is in English and therefore only women who had an adequate understanding of English could participate. This also limited the sample size. Women were not asked if their pregnancy was planned or unplanned as that was not deemed appropriate by the ethics committee. However, the response to this question would have revealed if women who planned their pregnancy took the recommended nutritional supplements and changed to a healthier diet. It would have been interesting to investigate the specific websites that women had visited before pregnancy as this would have enabled an assessment of the content of those websites that influenced the uptake of supplements before pregnancy. However, this may be problematic as websites can change content rapidly and it would be difficult to confirm the specific version that had been browsed.
Conclusions
This study found that women who used electronic information sources before pregnancy, were more likely to take folic acid at the correct time, but this uptake was still low. In fact, women who are currently using the internet, have expressed a desire to use mobile applications as an information source. An NHS pregnancy mobile application/website that allows direct interaction with preferred healthcare professionals e.g. nurses and community pharmacists could create a platform for motivational interviewing and support women in changing their behaviour to improve healthy nutrition and to use the correct supplements on time before becoming pregnant. Additionally, the endorsement of more government approved commercial applications and websites offering validated pregnancy information would reach more women.
This study highlights the discrepancy between pregnant women’s perceived and actual knowledge: Women thought their knowledge about nutrition and supplements was adequate and were satisfied with the advice they received. However, women did not take nutritional supplements on time exposing women’s lack of knowledge of the recommended guidelines and hence their lack of accurate knowledge. There is currently a gap in the provision of this information at the correct time, that is, before conception to ensure offspring are healthy and to help reduce the future disease burden. All healthcare professionals, including underutilised community pharmacists, in contact with women who are pregnant or thinking of becoming pregnant should be encouraged to promote the importance of taking supplements and good nutrition. Although this may require further relevant training.