Audit on Folate Supplements for Pregnant Women in Indonesia Assignment Sample

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Introduction

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Folate, also known as vitamin B9, stands as a critical micronutrient, playing a pivotal role in supporting maternal and fetal health throughout pregnancy. Its significance lies in its involvement in DNA and RNA formation, along with its contribution to protein metabolism (Harvard T. H. Chan, 2023). This micronutrient further governs processes like red blood cell production, cell division, and DNA synthesis, particularly crucial during the early stages of pregnancy when rapid cell development is underway (Whitney et al., 2019).

The optimization of the intake of folate supplements in the pregnant and lactating women is very much important for the growth and development of the child and also it may improve their health for a longer period of time. The intake of several macronutrients like vitamin E and D and other water soluble vitamins, iron and calcium of the pregnant and lactating women may be below the required level in some countries. So in those countries several nutritional programs should be conducted to improve the levels of folate in them.

The global prevalence of neural tube defects (NTDs) is a matter of significant concern, affecting a substantial number of stillbirths. With 2.5 cases per 1,000 stillbirths, the impact of NTDs on maternal and fetal health is undeniable (Flores et al., 2014; Kancherla et al., 2021). Particularly, developing countries face a higher estimated prevalence of NTDs, notably within the first five years of life (Madrid et al., 2023). Prevalence data on inadequate folate status in Indonesia remains notably underreported, despite the well-documented emphasis on the nutritional status of macro and micronutrients in pregnant women

The deficiency of folate includes several abnormalities in mothers' health. Those include anemia, neuropathy and some other congenital abnormalities to the fetuses. The supplementation of folate tablets can help to solve these problems in pregnant women. Some symptoms that help to identify the deficiency of folate include increased tiredness, decreased energy levels in the body, headaches, palpitations etc. Also severe muscle weakness can be seen and it may also include the soreness of tongue, ulcer in mouth etc. Problems with vision are also a major problem of folic acid deficiency in the body.

The gravest clinical consequence of folate deficiency is NTDs, which includes devastating conditions such as anencephaly (absence of brain formation) and spina bifida (incomplete closure of the neural tube) (Argyridis, 2019). These conditions typically develop between the 18th and 28th days of conception (West et al., 2017), underscoring the necessity for folate supplement interventions, particularly during the first trimester of pregnancy (Gomes et al., 2016). A wealth of research underscores the effectiveness of folate supplements in reducing the incidence of NTDs from 5.9% to 0.5%.

Literature review/knowledge gaps

Folate can be obtained through dietary sources and supplements, with rich food sources like spinach, liver, asparagus, and Brussels sprouts help to reduce the deficiency of folic acid in pregnant or lactating women to old age and also in children (Indonesian Ministry of Health, 2014a; Whitney et al., 2019; National Institutes of Health, 2022). However, recent findings from a systematic review reveal that dietary folate intake among Indonesian pregnant women often falls significantly short of the recommended daily intake (RDI), which ranges from 0 to 280 ug in Jakarta. Defects like neural tube can be prevented by the consumption of folic acid (Agustina et al., 2023). A folic acid supplement of around 400 mcg is required by a woman who is not even trying to get pregnant.

Another research gap pertains to the effectiveness and compliance with Iron and Folic Acid (IFA) supplementation programs recommended by the Indonesian Ministry of Health for pregnant women to protect the newborn babies from preterm and premature delivery and neonatal death in the early stage of pregnancy. These programs have been consistently implemented since the 1990s (Dibley et al., 2012; Indonesian Ministry of Health, 2014a). It has been identified that consumption of folic acid can help in the synthesis of nucleotides in the embryo to promote the DNA replication (Titaley et al., 2012, as cited in Octavia & Harlan, 2022). A broader exploration of the program's reach, effectiveness, and factors influencing adherence is warranted (Dibley et al., 2012). Moreover, evidence from other countries such as China and Nepal has indicated a significant reduction in child mortality rates due to IFA supplementation during pregnancy.

A notable research gap arises from a 2017 survey revealing low compliance with the recommended IFA supplementation regimen. Only 44% of respondents adhered to the prescribed intake of 90 tablets. Less consumption of folic acid tablets during the time of pregnancy can lead to other health problems such as diabetes associated with autism and other disabilities. The importance of folic acid also includes the prevention of several major birth problems of the infant's brain known as anencephaly and problems in the spine known as spina bifida (Noptriani & Simbolon, 2022). Consultation with a healthcare provider should be done by a pregnant woman or NTD affected pregnant woman. The recommendation of folic acid from the beginning of one month before the pregnancy and through the pregnancy for the first three months, it's around 4000 mcg. But the woman who previously got affected by NTD and not planning for pregnancy needs to consume 400 mcg of folic acid each day (Titaley et al., 2017). Understanding the factors influencing adherence and assessing the actual folate content in these supplements vis-à-vis the national guidelines is an essential avenue for research.

Folic acid is known as the form of folate which is manmade and it is a type of vitamin B. Folate is mainly found in different food items. Those include nuts,citrus types of fruits, vegetables and folic acid is also present in food which are fortified and in some vitamins. The role of folate is to make new blood cells in the body. These blood cells help to carry oxygen to the different parts of the body. So, if there are not enough red blood cells produced by the body then anemia can occur. The main main cause of anemia is when the blood is unable to carry the needed quantity of oxygen in the body. This makes the body pale and weak. If anemia occurs due to folate deficiency in the body then it is known as folate deficiency anemia. In Indonesia providing the supplements for IFA tablets for women specially who are pregnant has been a national health policy since the time of 1990. It has been advised by the doctors that a pregnant woman requires iron for about 60 mg and folic acid for about 0.25 mg on a daily basis for at least 90 days. Nutritional International mainly works with the government and encourages people to improve the nutritional health of pregnant women and provide them the nutritional services they need. This service mainly helps the women to adopt some healthy behaviors. In Indonesia this nutrition internationals helps to improve the maternal nutrition health of pregnant women. Their policies include strengthening the supply chain, capacity building of the health care providers and developing a behavior change.

In Indonesia nutrition international collaborates with the directors of the community nutrition, health promotion and maternal health care providers. Directors of the pharmacy under the Indonesian ministry of maternal health help to improve the intake of folic acid or IFA tablets and iron tablets between the pregnant women of Indonesia. Promoting an environment to provide women with their supplements has become a necessity in Indonesia. The women who are at their reproductive age in rural areas mainly suffer from energy deficiency disorders. The factors that affect the disorders involve decreased dietary quality, size of the family etc. Also studies showed that pregnant women are at a high risk of giving birth to premature babies who suffer from folate deficiency or folic acid deficiency. In Indonesia the consumption of micronutrients along with folate supplements is not a popular habit between pregnant women. Even in other countries the supplementation programs for pregnant women may not be implemented. So, the women suffer from many nutrient deficiency including iron deficiency, zinc deficiency. The maximum deficiency of micronutrients have been found among the lactating women in Indonesia may. People in Indonesia ignore many healthy food items in their daily diet plan which may help to increase their folic acid levels in the body.

Research Project Question

This research investigates IFA supplements available for pregnant women in two cities in Indonesia, Jakarta and Malang. Does folic acid content in the supplements meet the national recommendation for pregnant women in Indonesia?

Methodology

Study Design

This study aims to conduct a cross-sectional audit of folate supplements available in online and store-based pharmacies and retailers in Indonesia. A cross-sectional study audit aims to analyze publicly available supplements in Indonesia at a specific period and investigate how it compares with the Indonesian guidelines (Wang & Cheng, 2020).

Sourcing commonly available folate supplements

Data will be collected by researchers between August 2023 and September 2023, collecting product information of iron supplements is explained in Table 1.

In-store data collection

Two sampling methods will be done to collect in-store product information on folate supplements across nine large pharmacy chains and privately-owned pharmacies in Malang and Jakarta, Indonesia (Ken Research Private LTD, 2020). General Nutrition Centre (GNC) will also be sampled as it is an international pharmacy chain with a strong presence in Indonesia, with 58 franchises as of 2014.

Online data collection

Researchers will collect online product information on folate supplements across the four large pharmacy chains, including Century, Guardian, Watsons and GNC, which have websites with Indonesia's country code (GNC Holdings Inc, 2014). The search strategy for folate supplements in Bahasa includes ‘asam folat', and ‘folate' or folic acid and folate.

Government-supplied IFA products

Researchers will send a proposal to BPOM for a list of folate products available for the general population or targeted for pregnant women. From the provided list from the BPOM, the folate supplements will be compiled into the Microsoft Excel database for further analysis.

Data extraction

Extracted data will include: product , company, target population, type of product, dose (in ug or mg), dose per pack, pricing range and cost per unit in AUD, cost per 1,000ug for folic acid in AUD, presence of other nutrients, nutrient messaging.

Data analysis plan

The cross-sectional audit aligns with the study's objectives, entailing an analysis of publicly available supplements in Indonesia during a specific timeframe to evaluate their adherence to Indonesian guidelines (Wang & Cheng, 2020).

For product selection, the study will employ pre-established inclusion and exclusion criteria as delineated in Table 2.

Plans and Resources

Project Timeline using GANTT Chart is presented on Picture 1.

Ethical Considerations

Ethical considerations play a fundamental role in research, including nutrition studies. However, there are situations where nutrition research might be exempt from requiring formal ethics approval. The other factors that implies no requirement of ethical considerations include the proven benefits and safety of using folate tablets in pregnant women. As this concern is related with a wide range of interventions which is safe and well recognized (Bardosono et al. 2019). Also ethical considerations may not be useful while addressing a complicated health issue. As in this case the reaction of folate tables is related to several health issues. Some other factors are the care standard. In this scenario, ethical concerns related to providing autonomy and consent are less pressing as it is already recommended and established practice.

Ethical considerations may result in various effective consequences. These include the well-being of the participants. The exposure of pregnant women is very much difficult without these considerations. The supplementation may have some side effects that should be treated to protect the pregnant women and the fetus that is developing. The consents of the participants should be taken after giving them the proper guidance about the purposes, benefits and risks of the study. Pregnant women should have the chance to make a decision about participation. But the considerations may help to protect the participants' privacy.

The exemptions discussed in Australian and Indonesian contexts are explained in Table 2.

Intellectual Property Considerations

The proposed project builds on the work of SJ, who conducted a cross-sectional media audit of folate supplementation. This proposed initiative will continue a collaboration between FJ, SJ, JW, WR and JM.

The project supervisors reviewed the draft research proposal throughout the research process, and their feedback and comments were considered. CDU Students also established and maintained a document trail of the research process, including field notes such as chats using online messaging apps, photos taken using personal mobile phones and online database search using Google to build a spreadsheets database. The owner of the data is CDU Students and Project Supervisors. Each role is described on Table 3.

Communication Plan/Project Output

The project output will be a report using a qualitative research approach on a cross-sectional audit. The timeline for this project spans from July to October 2023. The proposed project outputs are a combined draft research paper and presentation. The details are as follows.

Combined draft research paper

The Indonesian Ministry of Health recommendation for pregnant women in Indonesia is to consume 90 tablets of IFA supplement once a day to achieve optimum maternal health during pregnancy.

Presentation

10-minute oral presentation at CDU Casuarina Campus on Friday, October 6 at 1400hrs ACST. The presentation would be presented to the stakeholders, lecturers and peers. The oral presentation aims to receive feedback, progress, and celebrate success.

Results and screening

The initial phase of this study involved compiling a comprehensive list of Iron and Folic Acid (IFA) products accessible through both in-store and online sources. A total of 68 IFA products were identified, with a breakdown of 45 originating from in-store sources and 23 from online platforms. Details concerning the products that were considered for identification can be found in Figure 1. It provides a comprehensive overview of the products included in the screening process.

Folavit 400 is manufactured by the company Sanbe Farma which is available in-store in Guardian, private owned pharmacy, and Century that contains 400 ug of folate in 2 tablets that is recommended for per day and recommended dosage per pack is 1x 10 tablet. The target population is pregnant women. The pricing range in AUD is $1.35 and cost per unit is $0.14 but the Indonesian government recommended $0.20 for 600 ug and cost per 1000 ug is $0.34. RDI% (600 ug of folate) of Indonesian government recommendation is 66 where RDI% (1000 ug of folate) of Australian government recommendation is 40.

Folabes is manufactured by the company Golden Corral Globalindo which is available at Kimia Farma (Jakarta) that contains 1000 ug of folate in 1 tablet that is recommended for per day and recommended dosage per pack is 1x 30 tablet. The target population is pregnant women. The pricing range in AUD is $4.20 and cost per unit is $0.14 but the Indonesian government recommended $0.21 for 600 ug and cost per 1000 ug is $0.35. RDI% (600 ug of folate) of Indonesian government recommendation is 66.67 where RDI% (1000 ug of folate) of Australian government recommendation is 40.

These indicators served to categorize the products based on their composition, revealing distinct subgroups within the dataset. The three primary subgroup categories are explained in Table 5.

According to the table Nuvita Nutri Folic is manufactured by the company Nutri Vita pharma which is available online and in-store in Watson that contains 1000 ug of folate in 1 tablet that is recommended for per day and recommended dosage per pack is 1x 100 tablet (Nahrisah et al. 2020). The target population is pregnant women and general. The pricing range in AUD is $9.80 and cost per unit is $0.098 but the Indonesian government recommended $0.06 for 600 ug and cost per 1000 ug is $0.098. RDI% (600 ug of folate) of Indonesian government recommendation is 166.67 where RDI% (1000 ug of folate) of Australian government recommendation is 100 (Noptriani & Simbolon, 2022). This oral supplement helps to prevent birth defects in newborn babies including neural tube defects and Spina bifida.

Folacite 1000 is manufactured by the company Erlimpex which is available online in Watson, that contains 400 ug of folate in 1 tablet that is recommended for per day and recommended dosage per pack is 1x 100 tablet. The target population is pregnant women (Diana et al. 2019) .The pricing range in AUD is $11.10 and cost per unit is $0.11but from the Indonesian government recommended $0.07 for 600 ug and cost per 1000 ug is $0.11. RDI% (600 ug of folate) of the Indonesian government.

Tablet Tambah Darah Neo Kf is manufactured by the company Kimia Farma which is available online in K-24 that contains 400 ug of folate in 1tablet that is recommended for per day and recommended dosage per pack is 1 x 10 tablet. The target population is pregnant women. It contains folic acid with other nutrients. The pricing range in AUD is $0.85 and cost per unit is $0.09 but the Indonesian government recommended $0.13 for 600 ug and cost per 1000 ug is $0.21. RDI% (600 ug of folate) of Indonesian government recommendation is 66.67 where RDI% (1000 ug of folate) of Australian government recommendation is 40.nt recommendation is 166 where RDI% (1000 ug of folate) of Australian government recommendation is 100. This supplementation helps to prevent preeclampsia in pregnant women.

Folavicap 1000 ug is manufactured by the company Capri Farmindo Laboratories which is available online in K-24 that contains 1000 ug of folate in 1 tablet that is recommended for per day and recommended dosage per pack is 10 x 10 tablet. The target population is pregnant women. The pricing range in AUD is $2.49 and cost per unit is $0.02 but the Indonesian government recommended $0.01 for 600 ug and cost per 1000 ug is $0.02. RDI% (600 ug of folate) of Indonesian government recommendation is 166 where RDI% (1000 ug of folate) of Australian government recommendation is 100.

The medicine Anelat is manufactured by the company d Ifars. It is mainly found in the online k-24. The target population is pregnant women. This medicine contains 1000 ug and recommended dosage is 1 tablet per day. This pack contains around 10 tablets in one pack. The pricing varies around $0.20 to $0.02 per unit in AUD. It mainly contains folate for around 1000 ug. It helps in the prevention of diseases.

Anemalot 1 mg is manufactured in Phapros company. The target group for this medicine includes pregnant and lactating women. It is found in online k-24. The recommended dosage is 0.5 or 1 tablet per day as per the doctor's advice. It contains 1000 ug dose. The recommended total folate dosage for this particular medicine is 500 to 1000 per day. The cost per AUD is approximately $0.04. The cost that is recommended by the Indonesian government per 600 ug is $0.02.

Data analysis

In a comprehensive evaluation, the study assessed folate supplements to ascertain their alignment with the national recommendation or Angka Kecukupan Gizi (AKG) for pregnant women in Indonesia. The relevant data can be found in Table 6.

The study has shown that the intake of both macronutrients and energy is very much from the required RDA/RNI level among pregnant women in Indonesia. The pregnant women also failed to meet the required levels of vitamin D, E and other water soluble vitamins. But the level of vitamin A and C in their body identified the required level.

Nutriwell Folic Acid 60's is manufactured by the company Vita shopindo which is available online and in-store in Watson, Guardian that contains 800 ug of folate in 1 tablet that is recommended for per day and recommended dosage per pack is 1x 60 tablet. The target population is pregnant women and general (Priliani et al. 2019). The pricing range in AUD is $14.80 and cost per unit is $0.25 but the Indonesian government recommended $0.19 for 600 ug and cost per 1000 ug is $0.31. RDI% (600 ug of folate) of Indonesian government recommendation is 133.33 where RDI% (1000 ug of folate) of Australian government recommendation is 80.

Maxpoferb is manufactured by the company Simex which is available in-store K-24 that contains 500 ug of folate in 1 tablet that is recommended for per day and per pack it contains 5 stripes per box, 2 effervescent tablets per strip tablet. The target population is pregnant, lactating, old age women. It contains folic acid with other nutrients. The pricing range in AUD is $12.29 and cost per unit is $1.23 but the Indonesian government recommended $1.47 for 600 ug and cost per 1000 ug is $2.46. RDI% (600 ug of folate) of Indonesian government recommendation is 83.33 where RDI% (1000 ug of folate) of Australian government recommendation is 50. Some studies have suggested in the results that the high dose of folic acid (100-800 ug) is more effective than the lower doses of folic acid (400-500 ug) (Alfiah et al. 2020). It includes the prevalence of folic acid deficiency and also Preeclampsia.

Tablet Tambah Darah Neo Kf is manufactured by the company Kimia Farma which is available online in K-24 that contains 400 ug of folate in 1 tablet that is recommended for per day and recommended dosage per pack is 1 x 10 tablet. The target population is pregnant women. It contains folic acid with other nutrients. The pricing range in AUD is $0.85 and cost per unit is $0.09 but the Indonesian government recommended $0.13 for 600 ug and cost per 1000 ug is $0.21. RDI% (600 ug of folate) of Indonesian government recommendation is 66.67 where RDI% (1000 ug of folate) of Australian government recommendation is 40.

It has been identified by the study that during the development of babies in the time of early stage of pregnancy, folic acid is required to create the neural tube. Also the importance of folic acid has been identified more precisely. As it helps to prevent the increased defects of the brain of the child. Though for the maximum number of women consumption of folate supplements for more than 1000 mcg on a daily basis shows no specific benefit. Only if the doctors advise the pregnant women to take excess dosage of plate supplements then they can consume as per requirement.

Discussion

Distribution channel and variety of products

The main four types of distribution channels include selling the product directly, selling the medicines through the intermediaries, distributing in a dual way and the channels which are reverse logistics. Every channel consists of different institutions whose main goals include the management of the transaction and the exchange of the products physically. Most aligning with the recommendations of a published article advocating daily multivitamin use to prevent anemia during pregnancy, featuring products like Sangobion, Tablet Tambah Darah, Maltofer, Feroglobin, Hemobion, and Sakatonik Activ (HelloSehat, 2023). When the women have the hemoglobin level of less than 12.0 g/dl then it is considered as anemia and among pregnant women when the level is less than 11.0 g/dl then it is considered as anemia. The concentration of hemoglobin varies by gender, physical status, smoking habit, age and altitude of the population where they live (Gamboa et al. 2020). The prevalence of this disease is approximately 46% among pregnant women in Jakarta and Malang. The risk factors resulting from maternal anemia includes the gestation and education level, consumption of IFA tablets in the time of pregnancy.

Cost comparison against Angka Kecukupan Gizi (AKG)

The availability and cost of folate supplements in Jakarta and Malang exhibit a significant range, with pricing converted to Australian dollars at an assumed exchange rate of 1 AUD to 10,000 IDR.The cost of the tablets may be different in Jakarta and Malang because of several factors such as the level of pricing, preferences of the brand and accessibility. These factors can also impact the budget of a pregnant woman and the total expenses of healthcare (Seu et al. 2019). As AKG provides guidance on daily intake of recommended important nutrients which also include folate, it needs to be considered that the need of the nutrient may vary person to person. As the cost is very much high so before taking the tablets pregnant women should consider a suggestion from their healthcare providers based on their circumstances. Also seeking out for some sources of folate which are affordable, like health programs sponsored by the government initiatives of the community can help the pregnant women get their required doses regardless of where they belong or their economic status.

In the places Jakarta and Malang pregnant women are mainly encouraged to get proper guidance to the nutritional requirements to meet their required nutritional needs. If the mother gets proper nutrition then their child can also fight with the deficiency of folic acid. Though the calculation of different logistic costs in Indonesia at a macro level, may face various problems. As this place doesn't have any specific national agreements or models to calculate the overall cost.

Cost comparison against average monthly expenditure per household

The International Labour Organization (ILO) data reveals that the total food expenditure per household in 2018 stood at 2,698,502 IDR in Jakarta and 2,033,635 IDR in Java Island (ILO, 2021). The monthly expenditure of the households can vary due to several factors such as rural or urban setting, location of the pregnant women and also the size of the family. The cost of the tablets can also vary depending on the type of brands. Several households, mainly those with less incomes who allocate a specific amount of their monthly income to spend per month, it is very difficult for them to buy folate tablets (Nahrisah et al. 2019). Access to different government supported programs and affordable healthcare facilities, play an important role in the availability of folate tablets to all. To promote the child health and maternal health affordability of public health programs are required. Also creating awareness about the importance of folate tablets among pregnant women and knowledge about its long-term health benefits can encourage the families to prioritize this folate nutrient.

Limited data mainly gathered by the Indonesian government due to the problems related to the cost analysis of the medications. This also occurs due to the use of limited technologies which is used to decrease the information asymmetry depending on the logistics and problems. The main recognition of the cost components and the formulation of the logistics has been more accurate in several cases.

Multivitamin-mineral supplements and national recommendations

In Indonesia, the recommended dietary intake for these supplements is quantified through the Angka Kecukupan Gizi (AKG), which signifies the average daily nutrient needs for diverse segments of the population, taking into account age, gender, physical activity levels, and physiological conditions. Folic acid which is also known as vitamin B9, which is a very important nutrient in the body to maintain various functions of the body. The recommended intake of folate tablets varies depending on several factors such as stage of life, sex and age. But there is a huge gap in the content of these folate tables compared to the content of multivitamins and single supplements (Agustina et al. 2023). A single folic acid tablet has more vitamin concentration than multivitamins, which provide a potent dose. It is beneficial for pregnant women who have specific dietary restrictions like requirement of excess folic acid. These supplements are typically available over the counter. Whereas, on the other side, multivitamins provide a wide range of nutrients to improve overall health conditions.

The RDA refers to different requirement levels for several nutrients in pregnant women. The common required nutrients are iron, folic acid, vitamin D, calcium and omega 3 fatty acids. Also the requirement of vitamin B and C is very important to them. Mainly pregnant women suffering from anemia occurring from iron deficiency, low quality diets, and smoking cigarettes face this deficiency related health problems. According to “World Health Organization (WHO)” the daily requirement of iron and folate supplementation includes 30-60 mf of iron which are elemental type and 400 up of folic acid.

Strengths and limitations of the study

This study implies a very important concern regarding public health. As the supplementation of folate tablets during the time of pregnancy is very much crucial to prevent complications like neural tube defects and leading the maternal and infant health to a healthy path. Also a casual relationship among supplements of folate and its health outcome has been established by this study (Jus'at, 2020). The long-term effects of folic acid in human health especially in pregnant women and infants has been identified. The reliability of the results have been enhanced by the monitoring of the supplement adherence.

Similar to other cross-sectional studies, this analysis also has the limitation of showing a cause-and-effect relationship. The study to other populations may not be generalized due to different factors. Those are genetic issues, diet therapy or the infrastructure of healthcare (Hadju et al. 2020). The confounding variables like overall diet therapy, the total socioeconomic status of the individuals and other health conditions are still not identified properly. However, these limitations are unlikely to reduce the validity of the results of the analyses.

In conclusion, the strengths of the study include factors like relevance to public health, the design of the study. Whereas, the limitations are indicating factors like regional specificity, confounding variables etc. It is very much essential to consider these factors while making the interpretation of this study.

Recommendations

Further research in the field of nutrition and supplementation is essential to improve the well-being of pregnant women continuously. Investigating factors affecting supplement quality, distribution, and demand, especially in regions like Jakarta and Malang, is critical for addressing disparities in prenatal nutrition. Public awareness campaigns are vital to inform individuals about the importance of making informed choices when it comes to their health. The recommended dosage of folate in pregnant women mainly helps to identify the difference between bioavailability of folic acid which is synthetic type and folate occurring naturally. The requirement increases during the time of pregnancy due to the role of folate in the synthesis of nucleic acid.

Conclusion

In conclusion, the findings of this research shed light on the critical relationship between folic acid content in prenatal supplements and adherence to national recommendations for pregnant women in Indonesia. Through collaborative efforts and ongoing dedication to this cause, we can make strides toward a healthier and more prosperous future for the people of Indonesia. The level of macro and micronutrients consumption in pregnant and lactating women in Indonesia is very much low from the required range. So the steps that should be taken by the Indonesian government include the initiation of several health programs. Providing supplements to the women in slum areas either for free or at a very nominal price can improve the intake of supplements among them.

Picture 1

GANTT Chart

Figure 1

Flow diagram of available IFA supplements in Jakarta and Malang

Table 1

Sourcing commonly available folate supplements

Sources

(i) in-store available supplements in Malang and Jakarta, Indonesia

(ii) online Indonesian-specific pharmacy websites

(iii) government-supplied IFA supplements from The Drug and Food Supervisory Agency of the Republic of Indonesia (Direktorat Registrasi Obat Tradisional, Suplemen Kesehatan dan Kosmetik, Badan Pengawas Obat dan Makanan Republik Indonesia/BPOM-RI) (BPOM)