One of the things that everyone agreed on during the long debates we’ve had on abortion in Ireland is that receiving a prenatal diagnosis of a foetal anomaly is a truly devastating thing to go through. Whatever our position on the right to life of unborn babies, our hearts go out to women and couples who have been told that their baby has a disability or condition that will have a huge impact on their life, or that may even result in their baby’s death before or shortly after birth. However, did you know that there is a safe, cheap and effective way of preventing some of these diagnoses from happening in the first place?
It has been well known, for decades, that women with folate deficiency are more likely to give birth to babies with neural tube defects such as spina bifida and anencephaly. Folate deficiency is common, but can be corrected by taking folic acid, which the body metabolises to folate, before and during early pregnancy. In fact, folic acid supplementation can decrease the risk of neural tube defects by 70% – quite a significant reduction. (1)
Furthermore, as drugs go, folic acid is as close to perfect as you can get. It is cheap: a three-month supply of folic acid is available in Tesco for 50c, with a brand name equivalent available for about €7. It has no known side effects. Folate is a water-soluble vitamin, which means any excess folate simply leaves the body through urination. This means that taking folic acid without actually being deficient in folate entails no risks. Folic acid is easily taken in the form of a tiny pill once per day – no need to inject, use a spray or an inhaler, or worry about bringing it on a flight as part of your carry-on luggage. And it is safe to take during pregnancy (obviously) and while breastfeeding.
The problem is, it’s not enough to take folic acid when you find out you’re pregnant. You need to start three months before conception. This is fine if you’re planning your pregnancy at least three months in advance, but not very helpful in the event of an unplanned pregnancy. We don’t know what proportion of pregnancies in Ireland are unplanned, but worldwide 40% of pregnancies are estimated to be unplanned (2), and we also know that most men and almost half of women did not plan their first sexual encounter. (3) It seems then that there’s a good argument for encouraging all sexually active women of childbearing age, regardless of their intentions surrounding pregnancy, to take folic acid supplements.
How to make this work in practice though? Informational campaigns encouraging us to do various things to protect our health rarely work – if they did, we’d have no smokers, no excessive drinkers, we’d all have fantastic diets and exercise regularly. Given this, there has long been a proposal to add folic acid to a food such as bread – but this has logistical difficulties concerning bread that is imported vs exported vs baked and consumed within Ireland, not to mention women who avoid bread altogether due to gluten intolerance or personal preference. The Minimise Project would therefore like to propose a new policy intended to boost the number of women taking folic acid as a matter of course:
GPs and pharmacists should automatically recommend or prescribe folic acid when they prescribe contraception
GPs typically encourage their female patients to take folic acid if they know their patient is sexually active but using a barrier – or even no – method of contraception, to ensure that these women will not be folate deficient should they become pregnant. While this is great, it’s worthwhile going a step further. The perfect use effectiveness of common forms of hormonal contraception such as the pill are very high – 99% – but the typical use effectiveness is only 91%. (4) GPs prescribe medication for typical women, not perfect women. Unless a GP knows for sure that all the women they prescribe the pill to will remain 100% compliant, won’t have any diarrhoea or vomiting and won’t take any contraindicated medications, they should expect that for every 100 of their patients who are prescribed the pill, nine will be pregnant within a year. This is pretty high. Wouldn’t it be great if those nine women, facing an unplanned pregnancy, didn’t also have to stress out about the fact that they weren’t taking folic acid when they became pregnant?
This policy also has the useful side-effect of reminding women and their partners, not to mention healthcare professionals, that contraception reduces – in some cases greatly reduces – the chances of pregnancy, but doesn’t eliminate them. Pregnancy is always a possibility, and it would be a great step towards a pro-life society if that fact was more widely acknowledged.
So, the Minimise Project proposes, as a new pro-life public health policy, that guidelines for GPs and pharmacists on issuing and filling prescriptions for contraception be updated to include an automatic recommendation for folic acid supplementation. This policy would not require any public funding or legislative change, can be easily and cheaply implemented, and could save many couples from heartbreaking diagnoses in the future.
Muireann
(1) https://www.thelancet.com/journals/lancet/article/PII0140-6736(91)90133-A/fulltext
(2) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4727534/
(3) http://www.ucd.ie/issda/static/documentation/esri/isshr-report.pdf
(4) Perfect use effectiveness is the proportion of women expected to become pregnant within a year when using the method of contraception absolutely perfectly, taking the pill every day, at the right time, and without any possible interference with the mechanism of the pill. Typical use effectiveness is the proportion of women expected to become pregnant within a year when using the pill at all, but perhaps not taking the pill every day as required, or having vomiting or diarrhoea which makes the pill less effective, or taking a medication or supplement that reduces the effectiveness of the pill.
The Minimise Project 