August 7, 2015

Should All Women Be Taking Folic Acid?

Guest blogger Aleka Gürel discusses the history of prescribing folic acid and the recent trend of including it in supplements for women who are not pregnant.

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Photograph of generic brand container of prenatal vitamins open and on its side, with pills spilled from opening.

Photograph of generic brand container of prenatal vitamins open and on its side, with pills spilled from opening.

If you’ve recently checked the nutritional information on the back of a women’s multivitamin or a LUNA women’s nutrition bar, you may have noticed that they contain a vitamin called folic acid. It may seem puzzling that products marketed to all women are being supplemented with a vitamin usually prescribed to those who are pregnant. While there’s a public health rationale for the practice, it is not without controversy.

What Is Folic Acid?

Folic acid is the synthetic form of folate, a B-vitamin found in leafy vegetables like spinach and broccoli. Folic acid supplements have been prescribed to pregnant women for decades in order to reduce the chance of their fetus developing a neural tube defect. Neural tube defects (NTDs) are a group of serious birth defects affecting the brain, spinal cord and spine, and include conditions such as spina bifida and anencephaly that can cause disability and death.

The History Of Prescribing Folic Acid To Women

In 1957, thousands of German women sought out a new drug, thalidomide, to relieve their morning sickness. Tragically, many of these women later gave birth to infants who suffered from severe disabilities as a result of their prenatal exposure to the drug. The scandal resulted in increased attention on the relationship between drugs and birth defects. In 1965, Elizabeth Hibbard and Richard Smithells published a study indicating a link between fetal malformation and folate deficiency. Subsequent studies of women who had already given birth to an infant with a neural tube defect found that taking folic acid supplements during a subsequent pregnancy reduced the risk of having another baby with an NTD by half. Physicians began to recommend the supplements first to mothers of children with NTDs, and then to all pregnant women.

However, in 1992, the CDC issued new guidelines advising women to start taking folic acid supplements before they became pregnant. Their reasoning was that most women do not know that they are pregnant until they have missed a period, at which point the fetus is several weeks old. Since folic acid’s protective effects can only act on fetuses in the first weeks after conception, many women were not taking the supplements early enough for them to make a difference. Because half of all pregnancies in the United States are unplanned, the current CDC guidelines advise that all women who are capable of becoming pregnant should take 400 micrograms of folic acid every day, so that if they do become pregnant, the vitamin can take effect immediately. In order to increase consumption of folic acid, in 1998 the U.S. mandated addition of the B-vitamin to enriched breads, pastas, rice and cereals. Recent research estimates that these mandates have helped avert 1300 NTD cases, saving $508 million in direct medical costs.

The Controversy

While most people agree that folic acid supplementation has helped reduce the number of babies born with NTDs, some scholars have argued that the trend towards supplementation has had some downsides. Historian Salim Al-Gailani writes that in the 1950s, NTDs were seen as a side effect of poverty and malnutrition, whereas today, women who give birth to children affected by these disorders are criticized as having failed to follow sound medical advice. This mentality ignores the fact that folic acid isn’t effective at preventing all cases of NTDs, and that some women may not be able to afford to buy folic acid supplements—not all states cover them for Medicaid recipients.

It’s also not just a question of who’s to blame for NTDs. Sociologist Miranda Waggoner argues that by telling women of childbearing age that they should take folic acid, the CDC frames all women as “pre-pregnant,” regardless of whether or not they want to have children. It’s now common for foods and supplements branded as being for “women” in general—not just those trying to conceive—to be fortified with the supplement. Waggoner notes that while this may have some practical public health benefits, it also reduces women to their ability to bear children: after all, men aren’t advised about what vitamins they should take before trying to conceive. Framing all women as pre-pregnant reinforces the deep societal connection between women & childbearing that fundamentally affects how women are encouraged and allowed to navigate their lives. The CDC’s folic acid guidelines serve as an important reminder that well-intentioned public health interventions can have unintended side effects.

Aleka Gürel is a recent graduate of Princeton University, where she majored in History of Science with a certificate in Gender and Sexuality Studies. She is interested in the history of pregnancy, childbirth and reproductive health technologies, especially in the context of 20th century Brazil.