Periconceptional supplementation with folate and/or multivitamins for preventing neural tube defects
RHL practical aspects by Bhutta ZA and Hasan B
FIRST CONTACT (PRIMARY CARE) LEVEL
A study in the USA documented that 95 % of the children born with neural tube defects (NTD) were from couples with no family history of these defects(1) and that the recurrence risk was 2-3 % in the subsequent pregnancy(2.) Others have indicated a much more variable pattern of inheritance and risk of recurrence. Therefore, whatever the mode of administration or dosage for folate supplementation, an effective plan should take into consideration the variable epidemiology and risk factors for NTDs. At the primary care level the following should be emphasised:
1) Since a substantial proportion of pregnant women in some developing countries particularly in South Asia and Subsaharan Africa consult traditional birth attendants and community health workers, an emphasis should be made on educating and training these health care providers as to the benefits of folate administration.
2) Women visiting health care facilities can be specifically targeted for health education in NTDs reinforcing the importance of prevention of this disorder by appropriate dietary measures and iron-folate therapy.
Such a multi-pronged approach to this problem may yield greater dividends than a focused single intervention. Currently however, it is not clear which approach is the most effective. Such a trial is underway in Hungary, the results of which are eagerly awaited.
REFERRAL HOSPITAL (SECONDARY CARE) LEVEL
The role of referral hospitals is to:
- Provide follow up antenatal care in women who have delivered newborn infants with NTDs in the past
- Identify at-risk women (especially those with previous births with NTDs) in respective catchment communities and support the community health providers in providing effective folate supplementation and education
- Reinforce public education in nutrition, risk factors for NTDs and prevention.
AT HOME OR IN THE COMMUNITY
Community education on the importance of folate intake is essential. A study from the USA(3,) described a community-based approach for tackling this problem. Initially, a statewide conference on NTD prevention was held for health care workers and health alerts were distributed to physicians and nurses providing care for women. In addition, television and radio advertisements, a television documentary film, brochures, posters etc were also used to increase public awareness regarding the benefits of folate supplementation. The aforementioned interventions were found to be beneficial and there was a significant decline in the prevalence rates of NTDs over a six-year period.
Public awareness can be increased using the communication media such as television, radio and newspapers. In addition, community awareness sessions on NTDs and the possibility of prevention would greatly help in raising awareness and assuring compliance to folate supplementation.
In developing countries, in addition to public health education, community health workers that principally provide support in domiciliary settings should be specifically targeted and trained in giving dietary advice and iron/folic acid supplements when needed. Given that the majority of the population in developing countries live in rural and deprived settings, it is necessary to direct the interventions for the prevention of NTDs to the community level.
- Folic Acid for the prevention of Neural Tube defects. American Academy of Pediatrics. Committee on Genetics. Pediatrics 1999;104:325-327.
- Hall JG, Solehdin F. Genetics of neural tube defects. Mental retardation and developmental disabilities research reviews 1999;4:269-281.
- Stevenson RE, Allen WP, Pai GS, Best R, Seaver LH, Dean J and Thompson S. Decline in prevalence of neural tube defects in a high risk region of the United States. Pediatrics 2000;106:677-683.
This document should be cited as: Bhutta ZA and Hasan B. Periconceptional supplementation with folate and/or multivitamins for preventing neural tube defects: RHL practical aspects (last revised: 7 January 2002). The WHO Reproductive Health Library; Geneva: World Health Organization.