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Does previous pregnancy experience improve folic acid supplementation uptake? A systematic review and meta-analysis.

  • 2026-05
  • BMJ open 16(5)
    • Utibe Ebong
    • Jason J Wilson
    • Joanne Given
    • Frank Casey
    • Maria Loane
    • Helen Dolk

Study Design

Type
Meta-Analysis
Sample size
n = 855
Population
81 studies involving 826 855 women (primiparous and multiparous women)
Methods
Systematic review and meta-analysis of observational epidemiological studies comparing folic acid use between primiparous and multiparous women

Objective

To examine whether multiparous women have more or less folic acid uptake than primiparous women.

Outcomes

Preconceptional, periconceptional and postconceptional folic acid use among all pregnant women and high risk pregnant women.

Design

Systematic review and meta-analysis.

Data sources

MEDLINE-Ovid, CINAHL Ultimate, Scopus and ProQuest Medical.

Eligibility criteria

Observational epidemiological studies comparing folic acid use between primiparous and multiparous women, published in English from January 1994 to June 2024.

Data extraction and synthesis

Two reviewers screened all papers meeting the eligibility criteria. One reviewer completed data extraction and assessed study quality using an adapted version of the Newcastle-Ottawa Scale. Three other reviewers independently assessed 10% of the studies as a quality check. Random-effects (DerSimonian and Laird) meta-analyses combined results for each outcome. Heterogeneity, risk of publication bias and certainty of evidence were assessed.

Results

Of the 10 982 records identified, 81 studies involving 826 855 women were included in the review. 27 studies were conducted in Europe, 22 in Asia, 11 in North America, 7 in Africa, 7 in Australia, 5 in the Middle East and 2 in South America. Multiparous women were consistently less likely to take folic acid before and during pregnancy than primiparous women. For preconceptional use, the odds were 29% lower among multiparous women (adjusted OR (aOR): 0.71; 95% CI 0.64 to 0.78; n=25 studies; I2=88.67%), and 58% lower in multiparous high-risk women (aOR: 0.42, 95% CI 0.27 to 0.64; n=3 studies; I2=27.28%). For periconceptional use, the odds were 32% lower among multiparous women (aOR: 0.68; 95% CI 0.63 to 0.74; n=28 studies; I2=85.46%). Postconception, the odds were 21% lower among multiparous women (aOR: 0.79; 95% CI 0.74 to 0.85; n=33 studies; I2=85.91%). By the second trimester, there was no significant difference between the two parity groups (aOR: 0.96; 95% CI 0.87 to 1.05; n=4 studies; I2=0.00%). The certainty of evidence was low for preconceptional, periconceptional and postconceptional uptake due to heterogeneity, and moderate for preconceptional uptake among high-risk women.

Conclusions

Multiparous women were less likely to take folic acid preconceptional, periconceptional and postconceptionally, despite their previous pregnancy experience. Barriers to folic acid supplement uptake among multiparous women need to be identified, and strategies to address them in preconception, antenatal and interconception care should be investigated.

Prospero registration number

CRD42024553241.

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