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Preventing neural tube defects

Editor—Kadir et al are less than thorough in their analysis of efforts to promote awareness and increased consumption of folic acid among women of childbearing age and the issues involved.1 The public education campaign run by the Health Education Authority began in February 1996, after the government's original strategy of exhorting doctors and nurses to give this new advice proved to be failing. It cannot be expected (bearing in mind the human reproductive cycle) that public health initiatives will have any effect on the incidence of neural tube defects in the same year they are launched; yet Kadir et al quote 1996 data to judge the effect of such efforts. 
 
They discuss the sale and prescribing of folic acid supplements as markers for increased consumption of folic acid. Yet they are unclear whether their quoted data refer only to supplements licensed as medicines, or also to unlicensed supplements, which are classified as food supplements and account for a large proportion of, if not most, folic acid preparations sold over the counter. 
 
The ultimate test of such a public health initiative is, however, whether it affects the incidence of neural tube defects. Kadir et al acknowledge that a longer interval may be required to show the true effect of supplementation on the incidence of neural tube defects. They did not have long to wait for data indicating such an effect. Only a few days after their paper was accepted for publication (January last year), the Office for National Statistics published statistics on congenital anomalies for 1997. In their commentary Alberman and Noble state that the rate of notification of anomalies of the central nervous system is the lowest to date—namely, eight per 10 000 births and abortions1—at a time when public awareness of the importance of folic acid in preventing neural tube defects is increased. Whether this reduction will be sustained remains to be seen, but it is a positive indication that public health efforts may be helping to reduce the incidence of these conditions. 
 
In a study by the Health Education Authority of pregnant and recently pregnant women in 1998, 65% of women who had planned their pregnancies claimed to have taken folic acid before conception, representing 38% of the total sample of women.2 None the less, efforts to promote folic acid need to be sustained, and the issue of unplanned pregnancies remains the biggest challenge in this area. The authority would welcome a greater recognition of the need for health professionals to give folic acid advice to all women of childbearing age, not only to those actively planning pregnancy. More comprehensive fortification of staple foods with folic acid would also help to address this area of concern.