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Prevention is better than cure

Ireland has one of the highest rates of neural tube defects (NTDs) in the world, with an incidence of 1.17 per 1,000 live births.

A total of 236 babies with an NTD were born between 2009 and 2011, a reverse in the trend from the previous decade.

On average, around 80 babies are born every year with an NTD but taking folic acid daily as a supplement could potentially prevent 70 per cent of those cases.

The issue of folic acid consumption in women of childbearing age has come to the fore this summer in Ireland.

A recently-published Irish study has revealed a decline in the number of food products fortified with folic acid, which means women are less likely to consume the vitamin passively in their diet. The number of fortified products in each food group has dropped sharply in the past decade, the study published in the Journal of Public Health found, even though the level of fortification has increased in those products to which folic acid is still added.

Taking folic acid as a supplement could potentially prevent two-thirds of neural tube defects every year – on average, that’s approximately 50 fewer babies affected every year

Breads, cereals, fruit juices, spreads and yogurts are among the products less likely to contain added folic acid, according to the researchers from DCU and UCD. The products that are still fortified tend to be in the niche ‘super/mega/vitamin-enriched’ category.

The recent rise in babies born with NTDs has been partly linked to the drop in passive folic consumption.

In recognition of the importance of the issue, in June the Oireachtas Joint Committee on Health heard from prominent experts on the importance of pre-pregnancy folic acid supplementation in the prevention of NTDs.


In July a new safefood campaign ‘Babies Know the Facts About Folic’ was launched, which urges all women who are sexually active and who could become pregnant to take folic acid daily, irrespective of whether they are planning a pregnancy or not.

The campaign has been developed to encourage women to take folic acid supplements and help address Ireland’s high incidence rate of NTDs like spina bifida among newborn babies.

Speaking at the launch of the campaign, Prof Michael Turner, UCD Professor of Obstetrics and Gynaecology at the Coombe Women and Infants University Hospital, said: “We know from recently-published Irish research that three-out-of-four women who attend for antenatal care have not taken folic acid supplements before they become pregnant. Taking folic acid daily as a supplement could potentially prevent two-thirds of neural tube defects every year — on average, that’s approximately 50 fewer babies affected every year.”

Dr Rhona Mahony, Master, National Maternity Hospital, Holles Street, continued: “We know that women are somewhat aware of folic acid but with up to 50 per cent of all pregnancies being unplanned, it’s so important that all women who are sexually active start taking the vitamin daily, even if a baby is the last thing on their mind. That’s because a baby’s neural tube develops in the first few weeks of pregnancy, when many women may be unaware they are pregnant.”

Speaking to the Medical Independent, Dr Mahony pointed out that NTDs can range from mild to very severe, terminal conditions like anencephaly, where most babies will die shortly after birth.

“The difficulty is the brain and spinal cord forms very early, in the first few weeks, between day 21 to day 28 so pre-conception folic acid intake is vital. By the time pregnant women come to hospital for their first check-up, it is too late to prevent an NTD,” she commented.

Intellectual disability is also common in babies born with NTDs, as is bowel and bladder incontinence, Dr Mahony said. While treatment for children born with NTDs has improved in recent decades, these are still very serious, life-long conditions. Surgery within 72 hours is required for many babies with an NTD to close gaps in the spine. Spina bifida can affect nearly all body systems to some degree, depending on the level of the lesion, with potential physical, motor, sensory, continence, cognitive and psychosocial difficulties.

“About one-third will require a wheelchair, one-third will require splints or assistance in walking and one-third will be okay with walking,” Dr Mahony said.

The life-long impact of spina bifida can have an estimated health services cost of €500,000. Provision and co-ordination of care for children with spina bifida, along with multidisciplinary team-working, is essential to optimise health and therapy outcomes.


Consumer research conducted by safefood for its campaign found that young adult women are misinformed, with less than 10 per cent of women surveyed taking folic acid routinely, while a further one-in-10 wrongly believed they got enough folic acid from the food they ate.

Research also shows that fewer women take folic acid during their second and subsequent pregnancies, which is putting them at risk of having a baby with an NTD.

Dr Cliodhna Foley-Nolan, Director of Human Health and Nutrition, safefood, added: “For a healthy mum and baby, we simply can’t get enough folic acid from our food alone, even with fortified foods — taking a daily folic acid supplement of 400mcg is the only way to go. Folic acid is widely available and doesn’t cost more than a few cents a day. Taking folic acid doesn’t mean you are planning a baby but just means when you do have a baby, however far in the future that may be, you are already helping to protect their health.”

Dr Mahony suggested that schools should teach female students about the importance of folic acid consumption and that maybe contraception should carry messages about it too.

A new research project being funded by safefood will also look at folic acid levels in women during the first trimester of pregnancy on the island of Ireland and will help inform future policy and practice around folic acid.

Supported by Spina Bifida Hydrocephalus Ireland and Shine NI, for more information on the safefood campaign, visit

The facts

Folic acid is a B vitamin (vitamin B9), which is essential for everyone’s health and women need extra during early pregnancy. Folic acid is not stored in the body, so people need to take it every day, and also cannot ‘overdose’ on it like some other vitamins that are stored by the body. Folic acid is a water-soluble vitamin that can be obtained from food (folates) or from supplements or foods that have it added to them (folic acid).

All adults need 200mcgs per day and this can be obtained from eating a healthy, balanced diet.

Women need an extra 400mcgs of folic acid in early pregnancy and because it is impossible to get this extra amount from a healthy, balanced diet, that is why a daily supplement is recommended.

Folic acid is a vital nutrient for the development of healthy babies in the womb. During the first weeks of pregnancy, the brain and spinal cord are developing rapidly and taking extra folic acid daily is needed to support this — 70 per cent of NTDs could be prevented by taking folic acid. This means that almost a third of NTDs do not respond to folic acid: “There are environmental and epigenetic factors as well,” added Dr Mahony.

Folic acid works best if it is taken before and during early pregnancy. It should be taken at least three months before getting pregnant to help reduce the risk of NTDs in unborn children. If already pregnant, women should start taking folic acid straight away and continue each day up to three months into their pregnancy.

It is best to take folic acid as an individual supplement because that ensures the right dose of 400mcgs a day. Some multivitamins may contain 400mcgs of folic acid but they may also contain vitamin A, which is not recommended during pregnancy.

Higher risk

Some women may be at a higher risk of having a baby with an NTD and should consult with their GP first about whether they need a higher dose of folic acid. The current HSE and RCPI nutrition for pregnancy clinical guidelines recommend women take a daily supplement of 400mcgs folic acid, with higher does required for those with certain risk factors, which would need a doctor’s prescription.

NTD risk categories

  • If the woman or her child has an NTD, for example spina bifida or hydrocephalus.
  • If the woman or their partner’s family have a history of NTDs.
  • If the woman is overweight or obese.
  • If the woman has type 1 or type 2 diabetes.

As the incidence of congenital malformations, including NTDs, are higher in obese women compared with normal women, the HSE currently recommends that obese women are prescribed a higher dose of folic acid to be given with prescription (4,000mcgs). Care should be taken when placing women on this higher dose of folic acid due to increased risk of colorectal adenomas with prolonged high-dose intake, the Irish guidelines warn.

Folic acid can also affect certain medications, for example anti-seizure medications for epilepsy, so women are advised to consult with their family doctor for medical advice and to discuss their options.

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