Background
Birth defects (BD) are a diverse group of abnormalities of prenatal origin that occur in relation to the structure or function of the individuals [
1,
2]. They are well known as a significant and a serious public health problem because of the high morbidity and mortality associated with them [
2‐
4]. Apart from the adverse outcomes in the affected individual, BD impose a huge burden on social, psychological, health aspects and economy of the caregivers and the family. Birth defects are known as a global health problem causing deaths of 303,000 newborns within the first 4 weeks of life each year worldwide [
5]. However, the occurrence and the impact of BD are found to be higher in low and middle income countries. More than 94% of serious BD occur in these countries and nearly 95% of the children with severe BD would die eventually [
1,
5]. It is said that these differences among developed and developing countries could be partly due to the differences in socio-economic conditions of the individuals and countries, availability of health care facilities and cultural aspects [
1]. In addition, lack of knowledge and education of the mothers on BD, the risk factors of BD and the prevention of BD have been identified as major factors which hinder the prevention of BD [
1,
2]. Because of the higher morbidity and mortality associated with BD, many countries were not able to achieve the United Nations Millennium Development Goal (MDG) 4 set as to reduce the under-five mortality rate by two-thirds between 1990 and 2015 even though the mortality due to most other causes showed a decline [
1,
2].
Sri Lanka, although being a country doing well in maternal and child health, has borne the burden of BD. A study conducted in Sri Lanka in 2014 has found a 4.3% prevalence of birth defects among newborns [
6]. Added to that BD have become a leading cause of mortality among children under 5 years in Sri Lanka and the proportional mortality due to BD has increased during the recent years [
1,
7‐
9]. In 2015 BD contributed 46.5% of infant deaths and 36.8% of 1 to 5 year child deaths [
8] and in 2016, the contribution for infant and 1–5 year child deaths was 54.5 and 34.5% respectively [
9]. Therefore, prevention and proper management of BD has become a priority issue in child health in Sri Lanka. With this background Sri Lanka initiated birth defects surveillance in 2014 and the pilot program was conducted in Galle district.
Though, BD carry a high morbidity and mortality they are considered to be preventable to a large extent [
2]. Several interventions such as preconceptional folic acid (FA) supplementation, iodization of food items like salt, immunization with rubella vaccine, screening and treatment of syphilis during pregnancy, identification and management of preexisting health conditions, improvement of nutritional status of the mothers have been each identified as cost-effective preventive strategies of BD [
1,
2]. Adding up to these interventions, health education of the mothers and the public has also been identified as a major method in the prevention of BD [
1].
Knowledge regarding BD and the management of BD is not only important for the prevention of BD, but for the betterment of the affected individuals as well. The higher the knowledge the parents or the care givers would be having, the higher the chances to reduce the morbidity and mortality associated with BD. Further, the affected children can be saved from adverse social outcomes like social stigmatization and from the extreme consequences like infanticide if mothers are aware on the management options of BD [
10]. Higher knowledge on BD, associated factors, prevention and management would invariably minimize the adverse social, psychological, health and economic impacts to the family and eventually the negative impacts to the country.
This study was planned to assess the knowledge of the antenatal mothers on BD, associated factors and prevention and management, and to identify the correlates of such knowledge. We also assessed the preconceptional FA intake and the awareness on the importance of preconceptional FA among the antenatal mothers in Galle, Sri Lanka.
Discussion
The knowledge on BD among the antenatal mothers in Galle, Sri Lanka was found to be moderate in all the components namely; knowledge on BD, knowledge on associated factors and knowledge on prevention and management. The overall knowledge on BD was 56.4%. This stresses the urgent need for Sri Lanka to pay more attention towards public awareness on BD, associated factors, prevention and management in order to reduce BD in the country in an era where BD cause a significant morbidity and mortality.
The mothers with higher educational attainment, mothers who were from wealthier families and mothers who had sought more antenatal care or had a higher number of clinic visits reported a better knowledge in all the components compared to the others. However, age, parity and having a child with BD did not show any association with the overall knowledge on BD. A study conducted in Ghana found that age, educational level, parity and number of clinic visits did not have a significant relationship with the knowledge on BD [
3]. Studies done in Nigeria and Iran found a positive relationship between the knowledge on BD and the level of education which is consistent with the results of the present study [
10‐
12]. A study done in Nigeria found a positive association between BD knowledge and age, social class, religion practiced and the location of the antenatal clinic center [
12]. They stated that mothers who had received care from a tertiary hospital have had a better knowledge on BD compared to mothers who had received care from a local hospital [
12]. The present study also was carried out at a community health area close to a medical faculty and two tertiary care hospitals. Therefore, the knowledge regarding BD could be higher among mothers who participated in the present study.
Our results indicate that mothers who had made more antenatal visits to health care workers or clinics have a higher overall knowledge on BD. Therefore, the primary health care workers of Sri Lanka should ensure the attendance of the antenatal mothers at least for the minimum number of clinics scheduled for the mothers. Special attention should be paid for the mothers with low educational and low socio-economic status. However, the number of antenatal visits depends on the period of gestation of the mothers. In the current practice of Sri Lanka, the antenatal mothers should make a minimum of nine field antenatal clinic visits and should receive three domiciliary visits in an uncomplicated pregnancy [
13]. The number of field visits and consultations by the consultant obstetrician depends on the risk assessment of the mother [
13]. It also varies according to the health seeking behavior of the mother. In contrast to the results of the present study, several studies have shown that there is no association between the number of antenatal visits and the knowledge on BD [
3,
11]. This difference in knowledge could be due to the routine nature of the antenatal clinics, the format of the antenatal sessions and the topics discussed at the antenatal clinics in the study setting. This might have been influenced by the health seeking behavior of mothers in the study area. Therefore, the antenatal care services and the health seeking behavior of the mothers in Galle, Sri Lanka seem to be effective in increasing knowledge on BD. Since the mothers should possess knowledge on BD ideally before they become pregnant, health education about BD should be commenced during the preconceptional period rather than during the antenatal period.
In this study group 62.3% (
n = 218) mothers have taken pre-conceptional FA. It is satisfactory compared to a study done in Kandy, Sri Lanka where preconceptional FA consumption among two groups; mothers with and without children with neural tube defects (NTD) was 0% and 13% respectively [
14]. Many researchers have found a low preconceptional FA intake among mothers in many communities [
15‐
17]. Some studies stressed on the low preconceptional FA intake even though many participants have heard about FA [
15,
17‐
19]. A study done in Taiwan, found that preconceptional FA intake was only 15.6%, though nearly 90% of the sample of women was aware of folic acid [
18]. It states about a possibility of these mothers getting aware of FA after they become pregnant, since the study was conducted among the antenatal mothers. A study done in Pakistan found that very few had received FA supplementation during pre-pregnancy and pregnancy period. According to them, only 51.25% had received FA even during pregnancy [
20].
We found that the preconceptional FA intake is positively associated with higher maternal age, higher educational level and lower parity of the mother. Nilsen and collegues also found a better preconceptional FA intake associated with higher maternal age, higher education, and lower parity which is consistent with our study [
16]. Several other studies also found that preconceptional FA intake is higher among mothers with higher education [
17,
19‐
21]. Therefore, Sri Lanka should pay further attention on education of the adolescent girls in the country. Within the education systems knowledge on reproductive health should be disseminated including the knowledge on BD and prevention. Through that, positive health behaviors like preconceptional FA intake by eligible females can be expected while increasing the awareness on BD, associated factors and prevention. Then Sri Lanka can achieve a reduction of BD, along with the associated morbidity and mortality.
This study revealed that preconceptional FA intake is higher among primiparous mothers (
p < 0.01). In Sri Lanka, a preconception care package was introduced in 2012 as a part of the maternal care package for the Sri Lankan mothers, particularly targeted for newly married couples [
9] and may be an explanation for the higher proportion of primiparous mothers taking preconceptional FA identified in our study results. Therefore, this finding of our study stresses the necessity of care before the subsequent pregnancies.
Among the mothers who have taken preconceptional FA only 5.04% stated that it prevents the BD of the nervous system of the baby and another 35.8% stated that it is needed for the development of the nervous system of the baby. About 14.2% (
n = 31) were not aware of the importance of preconceptional FA and the rest 44.9% (
n = 98) stated nonspecific or incorrect reasons on the importance of preconceptional FA. This finding stresses the fact that even the women who took FA preconceptionally, have inadequate knowledge about the importance of FA. If the mothers were aware on the NTD prevention associated with FA, the preconception FA intake would more likely to be much higher. Therefore, when prescribing FA to the eligible females it is important to highlight the importance of preconceptional intake of FA. Dissanayake and collegues concluded on a grossly inadequate knowledge on FA in Sri Lanka, even among the mothers having children with NTD [
14]. Many studies have revealed inadequate awareness about the importance of FA and stressed on the importance of public health strategies to increase awareness on FA [
14,
15,
19‐
23]. However, countries like Israel and Canada have shown a higher prevalence of folate awareness [
19]. It would be better to look for the methods they have used to achieve these targets when planning public health strategies to increase awareness on FA among Sri Lankan mothers.
According to the results of the present study no association between the socio-demographic factors and the knowledge on the importance of preconceptional FA was elicited. Our finding is consistent with the results derived by Nosrat and collegues [
15]. However, many studies showed associations between the awareness on FA and socio-demographics. An Ethiopian study revealed that women with better family income were more aware of the importance of FA [
21]. Many other studies revealed a better awareness on FA among females with higher educational attainment [
17,
19,
21,
22]. This might be an evidence for the fact that there is a lack in the education curriculums of Sri Lanka with regard to certain health aspects like BD prevention.
Prevention of NTD is highly associated with the “preconceptional consumption” of FA since the neural tube develops by the 28th day of gestation, a time period where the mother herself is not aware about the pregnancy [
17,
18,
24]. Two major methods, namely; creating awareness on FA and supplementation of FA among the females in the child bearing age have been identified as main preventive strategies against NTD [
18]. In the supplementation of folic acid for females in childbearing age, fortification plays a major role and the other method of supplementation is tablets containing FA [
2,
25]. Jou and collegues cited that fortification has shown a 31 and 16% reduction in the prevalence of spina bifida and anencephaly respectively in the United States once US has fortified the food with FA [
18]. Many other countries like Canada, Costa Rica, Chile and South Africa also have shown a significant reduction of NTD after food fortification with FA [
2]. In countries like Sri Lanka, where such a policy is not being practiced yet [
2], making the public aware on the importance of FA through health education would be the best method to reduce the NTD, which showed a prevalence of 1.4 per 1000 live births [
14]. With a better awareness on the importance of FA, preconception FA intake would be increased in the country. When making plans to make the eligible females aware of the importance of FA, it is important to make them aware from their adolescence while they are in the schools to have a better coverage.
Many researchers have investigated for the methods of acquiring knowledge about BD and FA among the communities. Many revealed mass media and health care workers as the main sources of information on BD and FA [
12,
17,
22]. When considering the methods of acquiring knowledge about BD in the present study, PHM, printed and electronic media were the leading sources of knowledge to the mothers. Dissanayake and collegues also stated family health worker as the main source of information on FA to the mothers followed by media [
14]. This may be due to the PHMs’ role as the grass root level health care workers in the delivery of field maternal and child care services in Sri Lanka. It might be further strengthened by the close relationship between the Sri Lankan mothers and the PHMs. This finding gives a positive feedback to initiate the BD prevention programmes through the PHMs, a well-established, strong platform with proven results in uplifting the maternal and child health in the country. Wide availability of electronic media like television and radio also has played a major role in delivering health messages to the community of Sri Lanka.
However, the knowledge on BD, gained through a medical officer is not satisfactory in this target group although in some studies medical practitioners were found to be the major source of information [
18,
19]. Therefore, public awareness through medical practitioners should be given more attention in Sri Lanka in order to prevent BD. A study conducted in Poland found internet as the major source of information for the participants of the study [
26]. This would be useful for Sri Lanka as well because the knowledge can be disseminated through internet and social media. This can be applied especially to the teenagers; the next generation of parents, among whom social media and internet usage is highly prevalent [
27]. Some studies have tested and proved the effectiveness of various health education methods and materials with regard to prevention of certain causes of BD [
28‐
31]. Many researchers have targeted on the awareness and intake of FA [
28‐
30]. The “Promotora de Salud model” which relied on interpersonal connections of the community health workers, has shown an increased awareness and practice of FA among the participants in several studies [
28,
29]. Sri Lanka also can practice this method through PHMs. Effectiveness of health education through village clinics, written materials and text messages was shown in a study conducted among rural Chinese women [
30]. A study done in Poland to assess the impact of health education on knowledge and prevention behaviour of congenital toxoplasmosis has stressed the necessity of modern promotional technologies apart from the traditional written education materials [
31].
For Sri Lanka, prevention of BD is a key priority in child health due to the fact that BD associated mortality is a leading cause for infant and 1–5 year child mortality. If the public is much aware about the gravity of BD, they would be interested in learning about BD and their prevention. According to a Nigerian study, 86.5% of the respondents believed that more public education can reduce the occurrence of BD [
4]. Therefore, public awareness through health education seems to be one of the major methods and a key priority in the prevention of BD in Sri Lanka. When planning the health education programs on BD in Sri Lanka, methods like education through PHMs and medical officers, distribution of pamphlets among the eligible females, giving messages through the electronic and social media and text (SMS) and video (MMS) messages need to be considered and implemented without any delays.
We gathered data from a sample of 350 antenatal mothers which is relatively a large sample. Data was collected from six field antenatal clinic centers. Data collection was performed by a single investigator which would have increased the consistency in data collection approach. These were the strengths of the study.
There were few limitations to the study. This study was confined to one health unit area. We were not able to recruit few (less than 5 %) participants from ethnic groups other than Sinhalese due to their inability to read and write Sinhala language. Also due to the self-administered nature of the questionnaire mothers might have understood the responses with minor variations.