Background: Preconception health, including adequate folic acid intake, is crucial for preventing adverse pregnancy outcomes like neural tube defects (NTDs). However, awareness levels often vary. This study aimed to evaluate the awareness of preconception health principles and folic acid supplementation among women of reproductive age in Shimla, Himachal Pradesh. Material Methods: A descriptive, cross-sectional online survey was conducted from September to December 2024 among 420 women aged 18-45 years residing in Shimla. A structured bilingual questionnaire assessed socio-demographics, knowledge of preconception health, awareness of folic acid (role, timing, dose, sources), attitudes, and practices. Data were analyzed using descriptive statistics; knowledge was categorized as Very Good (≥80%), Good (60-79%), Fair (40-59%), or Poor (<40%). Results: Participants were mainly aged 26-35 (48.8%), married (70.0%), and educated to graduate level or above (55.0%). While general awareness of lifestyle factors was fair (e.g., 72.4% knew about avoiding smoking/alcohol), specific knowledge about folic acid was limited: 58.1% knew its role in NTD prevention, 51.9% knew the correct timing (before conception), and only 35.0% knew the recommended dose (400 mcg). Overall knowledge classification showed 9.0% Very Good, 31.9% Good, 41.0% Fair, and 18.1% Poor awareness. Conclusion: Significant knowledge gaps regarding preconception health, especially concerning the specifics of folic acid supplementation, exist among women of reproductive age in Shimla. Targeted educational interventions through healthcare providers and community channels are urgently needed to improve awareness and promote healthier pregnancies.
Preconception health represents a critical cornerstone for ensuring optimal maternal and infant outcomes, yet it often remains an under-recognized aspect of reproductive healthcare. The period before conception offers a unique window of opportunity to identify and mitigate health risks, promote healthy behaviors, and optimize physiological readiness for pregnancy. Effective preconception care encompasses a range of interventions, including nutritional optimization, management of chronic conditions, screening for infections, cessation of harmful substance use, and importantly, supplementation with essential micronutrients like folic acid. Addressing health issues before pregnancy can significantly reduce the rates of adverse outcomes such as congenital anomalies, preterm birth, low birth weight, and maternal morbidity [1-4].
Among the key components of preconception care, adequate folic acid intake stands out for its proven efficacy in preventing neural tube defects (NTDs), such as spina bifida and anencephaly. NTDs arise very early in gestation, often before a woman is aware she is pregnant, making periconceptional folic acid supplementation (starting before conception and continuing through early pregnancy) crucial. International and national guidelines strongly recommend that all women of reproductive potential consume 400 micrograms of folic acid daily. Despite robust evidence and public health campaigns, awareness and adherence to these recommendations vary widely across different populations, influenced by factors like socioeconomic status, education level, access to healthcare information, and cultural beliefs [5-8].
In diverse settings like Shimla, Himachal Pradesh, understanding the local landscape of awareness regarding preconception health and folic acid supplementation is vital. Shimla's population encompasses a mix of urban and rural communities, potentially leading to disparities in access to health education and services. Limited awareness among women about the importance of preparing for pregnancy, the specific benefits of folic acid, and the correct timing and dosage for supplementation can act as significant barriers to uptake. Assessing the current knowledge levels, attitudes, and practices related to preconception care within this specific community is essential for tailoring effective public health strategies.
This study, therefore, aims to evaluate the awareness of preconception health principles and, specifically, the knowledge regarding the importance and use of folic acid supplementation among women of reproductive age in Shimla. By identifying knowledge gaps and potential barriers, the findings will provide valuable insights for developing targeted educational interventions and strengthening local healthcare services to promote healthier pregnancies and birth outcomes in the region.
Study Design
A descriptive, cross-sectional study utilizing an online survey methodology was conducted to assess the awareness, knowledge, and attitudes regarding preconception health and folic acid supplementation among women of reproductive age residing in Shimla, Himachal Pradesh.
Study Area and Population
The target population included women aged 18 to 45 years currently residing in Shimla (including both urban and surrounding semi-urban/rural areas accessible via online means). Eligibility was restricted to women within this age group who had access to an internet-enabled device (smartphone, computer, or tablet) and could comprehend the questionnaire presented in either English or Hindi. Women currently pregnant were not excluded, as preconception knowledge is relevant to future pregnancies, but specific questions might address timing relative to current/previous pregnancies.
Study Duration
Data collection was carried out over a four-month period, from September 2025 to December 2024.
Sample Size and Sampling Technique
Based on an estimated 50% prevalence of adequate knowledge about folic acid benefits (chosen conservatively due to lack of specific local data), a 95% confidence level, and a 5% margin of error, the minimum sample size was calculated to be 384. To account for potential incomplete responses, a target sample of approximately 420 women was aimed for. A non-probability, convenience sampling technique was employed. The survey link was disseminated through various online channels expected to reach women in Shimla, including social media platforms (Facebook groups, Instagram), messaging applications (WhatsApp groups related to local communities or women's interests), and potentially through collaboration with local NGOs or community health initiatives for online promotion.
Inclusion and Exclusion Criteria
Inclusion Criteria: Women aged 18-45 years, residing in Shimla, able to understand English or Hindi, access to an internet-enabled device, willingness to provide informed electronic consent.
Exclusion Criteria: Women outside the specified age range or not residing in Shimla, inability to provide consent, inability to use or access the online survey format.
Data Collection Instrument
A structured, bilingual (English and Hindi) questionnaire was developed and administered using Google Forms. The questionnaire was designed following a review of existing literature and relevant health guidelines, and validated through expert review and pilot testing. It comprised the following sections:
Socio-Demographic Information: Age, marital status, education level, occupation, area of residence within Shimla, parity (number of previous pregnancies/births).
Knowledge of Preconception Health: General awareness about the concept of preconception care, knowledge of lifestyle factors affecting pregnancy (e.g., smoking, alcohol, weight), awareness of chronic disease management before pregnancy.
Knowledge of Folic Acid: Awareness of folic acid/vitamin B9, knowledge of its role in preventing birth defects (specifically NTDs), awareness of recommended timing (before conception), knowledge of sources (supplements, fortified foods), awareness of recommended dosage.
Attitudes and Practices: Beliefs about the importance of preparing for pregnancy, reported intake of folic acid supplements (timing, regularity), perceived barriers to taking supplements or seeking preconception advice.
Sources of Information: Primary sources used for health information related to pregnancy and nutrition.
Pilot testing was conducted with 20 women from the target demographic (excluded from final analysis) to assess clarity, length, and technical aspects. Necessary revisions were made based on feedback.
Data Collection Procedure
The finalized survey link was shared on the selected online platforms. An introductory page clearly stated the study's purpose, assured anonymity and confidentiality, explained the voluntary nature of participation, and included the electronic informed consent form. Participants had to provide consent before accessing the questionnaire. IP address tracking was minimized to enhance anonymity, and settings were used to prevent multiple submissions from the same device where feasible.
Data Analysis
Data collected through Google Forms were exported to Microsoft Excel for cleaning and verification, then analyzed using appropriate statistical software (e.g., IBM SPSS). Descriptive statistics (frequencies, percentages) were calculated for all variables, including socio-demographic characteristics, knowledge levels (overall and specific to folic acid), attitudes, practices, and information sources. Knowledge scores could be calculated based on correct answers in the relevant sections and categorized (e.g., Poor, Fair, Good, Very Good) for further analysis if required.
Ethical Considerations
Ethical approval was sought from an appropriate institutional review board or ethics committee prior to data collection. Participation was entirely voluntary, and informed electronic consent was obtained from all participants. Data anonymity and confidentiality were maintained throughout the study process; no personal identifiers were collected.
Socio-Demographic Characteristics of Participants
A total of 420 women from Shimla district participated in the online survey. The majority were young adults aged 26–35 years (48.8%), followed by 18–25 years (25.0%) and 36–45 years (26.2%). Most participants were married (70.0%) and highly educated, with 55.0% having completed graduation or higher. Occupationally, 62.9% were employed, while others were homemakers (26.4%), students (8.3%), or unemployed (2.4%). Respondents came from both urban/semi-urban (60.0%) and rural (40.0%) areas. Regarding parity, 41.9% were nulliparous, and 35.0% had experienced one prior pregnancy, indicating a diverse reproductive background (Table 1).
Table 1: Socio-Demographic Characteristics of Participants (N = 420)
Variable | Category | Frequency (n) | Percentage |
Age Group (Years) | 18–25 | 105 | 25.0 |
| 26–35 | 205 | 48.8 |
| 36–45 | 110 | 26.2 |
Marital Status | Single | 95 | 22.6 |
| Married | 294 | 70.0 |
| Divorced/Widowed/Separated | 31 | 7.4 |
Education Level | Up to Higher Secondary | 189 | 45.0 |
| Graduate & Above | 231 | 55.0 |
Occupation | Employed | 264 | 62.9 |
| Homemaker | 111 | 26.4 |
| Student | 35 | 8.3 |
| Unemployed | 10 | 2.4 |
Residence Area | Urban/Semi-Urban | 252 | 60.0 |
| Rural Shimla | 168 | 40.0 |
Parity | 0 (Nulliparous) | 176 | 41.9 |
| 1 | 147 | 35.0 |
| 2 | 71 | 16.9 |
| ≥ 3 | 26 | 6.2 |
Awareness of Preconception Health and Folic Acid Supplementation
Participants answered 20 multiple-choice questions assessing knowledge about preconception health and folic acid. Overall, general awareness of lifestyle factors impacting pregnancy was reasonably good, with 72.4% recognizing the importance of avoiding smoking and alcohol. However, specific knowledge related to folic acid's function, timing, and dosage was lacking. Only 51.9% knew that folic acid is most crucial before conception, and just 35.0% identified the correct daily dose. Encouragingly, 70.0% knew to consult a healthcare provider before planning pregnancy (Table 2).
Table 2: Awareness of Preconception Health and Folic Acid Supplementation (N = 420)
Question | Options | Correct (n) | % |
What does "preconception health" refer to? | a) Health during pregnancy only, b) A woman's health before she becomes pregnant, c) Health of the newborn, d) Health after delivery | 277 | 66.0 |
Why is a healthy weight important before pregnancy? | a) Only affects appearance, b) Guarantees easy delivery, c) Reduces risks for mother and baby, d) No impact on pregnancy | 290 | 69.0 |
Which factor should be addressed before conceiving? | a) New exercise routine, b) More caffeine, c) Stop smoking/alcohol, d) Stressful job change | 304 | 72.4 |
What is folic acid? | a) Painkiller, b) Antibiotic, c) B-vitamin (B9), d) BP medication | 260 | 61.9 |
Primary benefit of folic acid pre-pregnancy? | a) Prevents nausea, b) Guarantees baby boy, c) Prevents neural tube defects, d) Increases chance of twins | 244 | 58.1 |
What are Neural Tube Defects (NTDs)? | a) Colds in newborns, b) Hearing issues, c) Birth defects of brain/spine, d) Skin rashes | 227 | 54.0 |
When is folic acid most crucial to prevent NTDs? | a) Only in 3rd trimester, b) After pregnancy confirmation, c) Before conception and early pregnancy, d) When tired | 218 | 51.9 |
Why take folic acid before conception? | a) Not important, b) Helps conception, c) NTDs form early, before many know they’re pregnant, d) Prevents stretch marks | 231 | 55.0 |
Recommended daily dose of folic acid? | a) 40 mcg, b) 4 mg, c) 400 mcg, d) 1000 mg | 147 | 35.0 |
Can a normal diet alone provide enough folic acid? | a) Yes, easily, b) Only if organic, c) No, supplements are recommended, d) Only with meat daily | 193 | 46.0 |
Good dietary sources of folic acid? | a) Sugary drinks, b) Red meat, c) Leafy greens, cereals, lentils, d) Dairy only | 273 | 65.0 |
Should women with prior NTD pregnancy take more folic acid? | a) Yes, higher dose prescribed, b) No, same dose, c) Avoid folic acid, d) Take lower dose | 185 | 44.0 |
Do all multivitamins contain enough folic acid? | a) Yes, b) Not necessarily – check label or add supplement, c) Yes if expensive, d) No multivitamins have folic acid | 206 | 49.0 |
Any serious side effects of folic acid at recommended dose? | a) Severe allergy, b) Weight gain, c) No, generally safe, d) Causes infertility | 265 | 63.1 |
Should chronic health conditions be managed before pregnancy? | a) Yes, reduces risks, b) No, doesn’t matter, c) Can wait until later, d) Only if severe | 311 | 74.0 |
Should vaccinations be updated before pregnancy? | a) Yes, to prevent infection risks, b) No, unsafe, c) Only childhood vaccines matter, d) Vaccines don’t affect pregnancy | 298 | 71.0 |
Is preconception care needed only for first-time mothers? | a) No, important before every pregnancy, b) Yes, c) Only after age 35, d) Only for high-risk women | 256 | 61.0 |
Who should women consult for preconception and folic acid advice? | a) Friends/family, b) Online forums, c) Doctor/nurse/healthcare provider, d) Pharmacist only | 294 | 70.0 |
Can a partner’s health impact conception and pregnancy? | a) Yes, it affects fertility/pregnancy, b) No, only woman’s health matters, c) Only if genetic issues, d) Only age matters | 223 | 53.1 |
Should folic acid be started if pregnancy is unplanned? | a) Yes, start as early as possible, b) No, too late, c) Only if doctor prescribes, d) Take very low dose | 319 | 76.0 |
Knowledge Score Classification
Based on their total correct answers to the awareness questions, participants were classified into four categories. The largest group (41.0%) demonstrated ‘Fair’ knowledge, while 31.9% had ‘Good’ knowledge. Only 9.0% achieved a ‘Very Good’ score (≥80% correct answers), and 18.1% showed ‘Poor’ awareness. These results highlight the need for enhanced public education on preconception care, especially in areas such as timing, dosage, and nutritional importance of folic acid (Table 3).
Table 3: Knowledge Score Classification Regarding Preconception Health and Folic Acid (N = 420)
Knowledge Category | Score Range (%) | Frequency (n) | Percentage (%) |
Very Good | ≥ 80 | 38 | 9.0 |
Good | 60 – 79 | 134 | 31.9 |
Fair | 40 – 59 | 172 | 41.0 |
Poor | < 40 | 76 | 18.1 |
This study aimed to evaluate the awareness of preconception health principles and folic acid supplementation among women of reproductive age in Shimla, providing crucial insights into the knowledge landscape within this specific demographic. The findings reveal a mixed picture: while general awareness about the importance of healthy lifestyles before pregnancy appears reasonably good, significant and concerning gaps exist, particularly regarding the specifics of folic acid supplementation—its critical timing, recommended dosage, and primary role in preventing neural tube defects (NTDs). The observation that less than half the participants knew the recommended daily dose of folic acid (35.0%) and just over half understood its crucial periconceptional timing (51.9%) underscores a major public health challenge.
The socio-demographic profile of the participants, predominantly married women aged 26-35 with relatively high education levels, suggests that even among segments often presumed to have better access to information, critical knowledge gaps persist. The fact that 41.0% fell into the 'Fair' knowledge category and 18.1% into 'Poor' indicates that awareness is not uniformly distributed and that targeted interventions are necessary across various demographic groups, including those with higher education. While the study found encouragingly high awareness (70.0%) regarding the importance of consulting a healthcare provider before planning pregnancy, this does not seem to translate into adequate specific knowledge about vital preventive measures like folic acid supplementation, suggesting a potential disconnect between general advice-seeking behaviour and the retention or provision of specific, actionable information during consultations.
The knowledge deficits identified in this study, particularly concerning folic acid, align with findings from other research in India and globally, which consistently report suboptimal awareness and practices related to preconception care. The potential consequences of these gaps are significant, as inadequate folic acid intake before and in early pregnancy remains a leading preventable cause of devastating NTDs. The finding that only 58.1% correctly linked folic acid to NTD prevention highlights a need to reinforce this specific message clearly and repeatedly through public health campaigns and clinical encounters. Furthermore, the relatively low awareness about the difficulty of obtaining sufficient folic acid from diet alone (46.0%) emphasizes the importance of promoting supplementation as the most reliable strategy.
This study's strengths include its focus on a specific geographic region (Shimla) encompassing both urban and rural respondents accessed via online means, allowing for a snapshot of awareness in a diverse setting. The use of a structured questionnaire covering various aspects of preconception health provides comprehensive data. However, certain limitations must be acknowledged. The reliance on convenience sampling through online platforms might introduce selection bias, potentially overrepresenting women who are more digitally literate and possibly more health-conscious, thereby potentially underestimating the knowledge gaps in the broader population, especially among those without internet access. Furthermore, self-reported knowledge does not always correlate perfectly with actual health behaviours.
Future research could employ mixed-methods approaches, including qualitative interviews to explore barriers to knowledge acquisition and supplement use, and utilize community-based sampling to reach a more representative population segment, including those less accessible online. Intervention studies evaluating the effectiveness of tailored educational programs in Shimla are also warranted.
The implications of these findings for public health policy and practice in Shimla are clear. There is an urgent need for enhanced, multi-channel educational strategies targeting women of reproductive age. These should go beyond general advice and focus explicitly on the "what, why, when, and how much" of folic acid supplementation. Healthcare providers (doctors, nurses, community health workers) are pivotal and need support and perhaps further training to consistently deliver clear, actionable information about preconception care during routine visits. School health programs could also incorporate age-appropriate information on reproductive health planning. Community-based campaigns leveraging local media and networks may be effective in reaching women across different socio-economic strata. Addressing these knowledge gaps is a crucial step towards improving maternal and infant health outcomes in the region.
In conclusion, this study highlights significant gaps in awareness regarding essential preconception health practices, particularly the critical role, timing, and dosage of folic acid supplementation, among women of reproductive age in Shimla. Despite reasonable understanding of general healthy lifestyle principles, the specific knowledge required to effectively prevent neural tube defects through timely folic acid intake is notably deficient across various demographic groups. These findings underscore an urgent need for targeted, comprehensive educational interventions delivered through healthcare systems and community platforms to empower women with the knowledge necessary for optimizing health before conception, ultimately contributing to healthier pregnancies and improved birth outcomes in Shimla.
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