Making birth defects ‘preventable’: Pre-conceptional vitamin supplements and the politics of risk reduction

Salim Al-Gailani

doi:10.1016/j.shpsc.2013.10.009

Abstract

Since the mid-1990s, governments and health organizations around the world have adopted policies designed to increase women’s intake of the B-vitamin ‘folic acid’ before and during the first weeks of pregnancy. Building on initial clinical research in the United Kingdom, folic acid supplementation has been shown to lower the incidence of neural tube defects (NTDs). Recent debate has focused principally on the need for mandatory fortification of grain products with this vitamin. This article takes a longer view, tracing the transformation of folic acid from a routine prenatal supplement to reduce the risk of anaemia to a routine ‘pre-conceptional’ supplement to ‘prevent’ birth defects. Understood in the 1950s in relation to social problems of poverty and malnutrition, NTDs were by the end of the century more likely to be attributed to individual failings. This transition was closely associated with a second. Folic acid supplements were initially prescribed to ‘high-risk’ women who had previously borne a child with a NTD. By the mid-1990s, they were recommended for all women of childbearing age. The acceptance of folic acid as a ‘risk-reducing drug’ both relied upon and helped to advance the development of preventive and clinical practices concerned with women’s health before pregnancy.

Highlights

Policies to encourage folic acid consumption are characteristic of the emphasis on risk prevention that came to dominate the management of health and disease in developed countries after 1945 (Berridge, 1999; Brandt, 1997; Rothstein, 2003)
I suggest that the controversy mobilized a heterogeneous set of actors—research scientists, clinicians, food and drugs companies, activists and journalists—with different interpretations of risk and uncertainty to claim a stake in pre-conceptional vitamin supplements as a means of preventing neural tube defects (NTDs)
Launching a clinical trial in 1977, Smithells would transform folic acid from a routine prenatal vitamin to reduce the risk of anaemia into an experimental drug for preventing NTDs in ‘high-risk mothers’

Summary

Introduction: folic acid and risk reduction

Since the mid-1990s, governments and health organizations around the world have adopted policies designed to increase women’s dietary intake of ‘folic acid’ before and during pregnancy in order to reduce the risk of having a baby with a defect of the brain and/or spinal cord. Expert disagreement over mandatory folic acid fortification has generated considerable international policy controversy over such issues as individual versus social responsibility, medical surveillance, the effectiveness of health education, and the risk and benefits of population-based interventions with unknown long-term consequences. This article puts these global debates aside for in order to recover the ‘natural history’ of folate deficiency in pregnancy as a health risk.. The second half of the article analyses the controversy around the MRC clinical trial and its immediate aftermath This focus illuminates the multiple constituencies involved in the co-construction of folic acid as a risk-reducing drug and pre-conception care. I suggest that the controversy mobilized a heterogeneous set of actors—research scientists, clinicians, food and drugs companies, activists and journalists—with different interpretations of risk and uncertainty to claim a stake in pre-conceptional vitamin supplements as a means of preventing NTDs

From Marmite to folic acid: vitamin supplements in pregnancy

Trialing pre-conceptional vitamin supplements and ‘high-risk mothers’

Constructing pre-conceptional nutrition

Findings

Conclusion