Folic acid paradox in Sudan: high clinical compliance versus critical delays in periconceptional initiation

Abstract

Periconceptional folate supplementation is critical for preventing neural tube defects (NTDs), yet timely initiation remains a global challenge. Despite established clinical guidelines, significant gaps in health literacy and structural barriers often lead to delayed supplement initiation, particularly in developing and conflict-affected regions.This study evaluated folate awareness, intake patterns, and dietary literacy among pregnant women (n=125) attending a military maternity clinic in Omdurman, Sudan. Structured questionnaires were used to assess maternal knowledge of periconceptional folic acid supplementation and dietary folate literacy. The results showed that only 51.2% of respondents recognized the importance of pre-pregnancy folate supplementation, leaving 48.8% unaware. Hospital safety nets provided free iron-folate (Fefol) prescriptions to 39.2% of participants. Although 58.4% initiated folate in the first trimester, 32.8% delayed intake until the second (29.6%) or third (3.2%) trimesters, missing the critical window for neural tube closure. Compliance with medical professionals was high, with 93.6% obtaining a prescription from a doctor. Crucially, 4.8% of participants reported a history of an NTD-affected pregnancy. Regarding dietary literacy, 21.6% lacked any nutritional knowledge, though animal-based sources (liver: 78.4%, fish: 70.4%), citrus fruits (71.2%), and green leafy vegetables (69.6%) were widely identified. Knowledge of common botanical sources remained fragmented. Significant gaps in preconception awareness and critical delays in supplement initiation persist despite high clinical compliance.While compliance with formal medical authority is strong in this study, a critical window of developmental vulnerability remains due to late supplement initiation and fragmented dietary literacy. Public health interventions in this population should shift from a reactive, purely prescriptive pharmaceutical model to a proactive periconceptional framework. This can be achieved by leveraging mass media, utilizing visually driven localized food charts, and expanding the educational role of nursing staff during antenatal care.