The incidence of various congenital anomalies has been an ever-growing problem. Although, various approaches have been underway to pinpoint the exact risk contributing mechanisms, Nutrition has turned to be a reliable intervention strategy. The relation between peri-conceptional folic acid intake and Neural tube defects (NTDs) has become the area of much research interest. It was reported that the incidence of NTDs could be reduced with the consumption of Peri-conceptional folic acid (Abu-Hammad et al., 2008).
This was revealed when a study was conducted to determine the impact of current health care practices adopted by physicians concerned with the care of childbearing women (Abu-Hammad et al., 2008). Here, a large number of physicians have reported a good response rate which accounted for 94%, indicating the efficacy of their recommendation to their patients. However, they have also reported a decline in the overall knowledge about folic acid’s role in minimizing NTD’s(Abu-Hammad et al., 2008).
They have noted two contrasting results. One is 2% knowledge about the folic acid role which was proven to be sub-optimal (Abu-Hammad et al., 2008). The second one is an 8% knowledge indicating the precise connection between folic acid intake and the incidence of other abnormalities (Abu-Hammad et al., 2008). Hence, this report has indicated a dearth in the awareness of folic acid supplementation (Abu-Hammad et al., 2008).
Recently, molecular analysis has shed further insights on the risk of NTDs and gene polymorphisms (Pei et al., 2009). RFC1 A80G gene was implicated as a carrier gene and its interaction with maternal periconceptional use of folic acid was studied by genotyping (Pei et al., 2009). The results have indicated that prospective mothers with GG genotype and no instances of folic acid intake were at high risk of NTD’s (Pei et al., 2009).
In contrast, others with AA or GA genotype and with the habit of maternal periconceptional folic acid intake were far from acquiring the risk. Therefore, RFC1 can be considered an important gene in folate transportation. Hence, this has indicated a strong relationship between periconceptional folic acid intake and NTDs.
Identification of the policy options available in response to the epidemiological evidence and the scientific and ethical dilemmas associated with each of these options that are confronting policy-makers
In countries like the United States and developing countries, there are some issues on the peri-conceptional folic acid intake to neural tube defects (NTDs) (Pérez-Escamilla, 1995). It was revealed that the recurrence of NTD’s can be minimized with high-dose folic acid during peri-conception (Pérez-Escamilla, 1995). This is because there were some inconsistencies and dilemmas regarding the accurate dose of folic acid. To this end, it was described that women with earlier abortions should seek physician’s guidance to avoid a recurrence (Pérez-Escamilla, 1995). Hence, the knowledge of the required dose is vital in lessening the incidence of NTD’s.
This has strengthened the available policy issues in countries like the US where dietary counseling was given due importance in managing women of childbearing age (Pérez-Escamilla, 1995). This report has also warranted the utility of folate enriched diet in developing countries and increased the efforts to prevent NTDs through widespread food fortification (Pérez-Escamilla, 1995). Although the prevalence of NTD’s is low earlier, the intake of folic acid may help in understanding the benefit/risk ratio in the future (Pérez-Escamilla, 1995). This could be achieved by undertaking large studies across various nations and pooling up the data. Hence, screening the dosage levels can be considered as the identified policy options about the growing body of scientific and ethical dilemmas.
In another policy option, researchers have undertaken a surveillance program that involved screening various obstetrics departments in hospitals (Klusmann et al., 2005). They noted that Neural tube defects (NTDs) carry an enhanced risk of inducing serious mortality and morbidity. Here, the information required was about the cases of NTDs in all abortions, live births, and stillbirths. Their findings indicated that the consumption of folic acid was less in the general population as evidenced by a slight drop in the incidence of NTD’s (Klusmann et al., 2005). This has increased the hope on the implementation of recommendations to anticipate a much decrease in NTD’s shortly (Klusmann et al., 2005). This has implications for lessening the scientific and ethical dilemmas associated with folic acid intake.
Earlier workers have reported that there is a need to develop awareness among health care professionals especially obstetricians and gynecologists about the efficacy of supplemental folic acid for the prevention of neural tube defects (NTDs)(Locksmith and Duff, 1998). They have made a retrospective analysis of data collected between 1990 and 1997. It was found that the literature demonstrates a reduction in the incidence of NTD’s corresponding to high folic acid intake (Locksmith and Duff, 1998).
Medications involving folic acid tablets were considered to be reliable in ameliorating an individual’s folate status, provided some concerns on the use of vitamin tablets were guaranteed (Locksmith and Duff, 1998). This has indicated that childbearing women or those of reproductive age are strongly advised to accept multivitamin supplements at a dose of 0.4 mg daily (Locksmith and Duff, 1998). Similarly, for women with an earlier abortion and who are proposed to become pregnant, the dose of folic acid is 4 mg to avoid the risk of miscarriage another term(Locksmith and Duff, 1998).
Description of the competing values, beliefs, and interests (if any) among stakeholders (where they can be identified) towards mandatory folic acid fortification as a policy response to the epidemiological evidence
Researchers have undertaken a study on awareness programs regarding the association between periconceptional folic acid intake and a reduction in the cases of primary and secondary neural tube defects (NTDs) including other congenital malformations (Bener et al., 2006). Here, much interest was shown on child-bearing women who were likely to run the risk of congenital anomalies (Bener et al., 2006). The policymakers have employed a multistage sampling design and studied nearly 1480 women with antenatal cases at various primary health care centers and women’s hospitals in Qatar (Bener et al., 2006).
It was revealed that most participants were comfortable with the questionnaires and in furnishing relevant information like folic acid supplements, pregnancy intention, and geographical and socioeconomic conditions (Bener et al., 2006). This study has suggested the significance of programs that includes a large population and the factors that influence the result with the scope of improving awareness and consumption of a diet rich in folic acid (Bener et al., 2006).
Hence, the awareness programs can be better identified as a step towards mandatory folic acid fortification to be implemented in many countries. In addition, the interest shown by the women participants could increase the confidence among the health care professionals and/ or stakeholders to take measurable steps in implementing folic acid fortification as a policy response to the epidemiological evidence. Chan et al. (2008) determined the folate awareness among household women.
They have employed a computer-generated database and conducted telephonic interviews. This has resulted in drastic improvements in the awareness of folic acid intake and its efficacy in reducing NTDs (Chan et al., 2008). A significant percentage of knowledge (25% to 77 %) and 12 % to 39 % was revealed in the intervention program on the knowledge on folic acids role and its necessary future directions for the periconceptional period (Chan et al., 2008).
This has indicated that the interest and belief in voluntary folic acid fortification could increase knowledge about peri-conceptional folic acid, enhance folate consumption, and an overall reduction in the prevalence of NTDs in South Australia (Chan et al., 2008). NTD’s are likely to be connected to other health problems and maternal and fetal risk factors (Chan et al., 2008). This has further strengthened the epidemiological evidence.
Therefore, there is an urgent need to focus on NTDs keeping given some reported parameters like maternal fumonisin consumption, periconceptional zinc deficiency, parental occupational exposure and residential proximity to pesticides, lower socioeconomic status, fetal alcohol syndrome, mutations in the VANGL1 gene, human athymic Nude/SCID fetus, and single nucleotide polymorphism in the NOS3 gene (Chen, 2008).
Analysis of the relevance (or otherwise) of the different policy-making theories presented in this unit to the circumstances of the case study
Parameters that better dissect the relationship between risk factors and the NTD pathology could improve the understanding of the circumstances that focus on the case study, especially concerning nonsyndromic multifactorial NTDs (Chen, 2008). Similarly, intervention programs that highlight the significance of national campaigns should be given prior importance by the health care professionals in improving the policy theories.
Amitai et al. (2004) reported that the guidelines issued by the ministry of health could better serve to lessen the risk of NTD’s. They have surveyed 1661 subjects to determine the knowledge among pregnant women and mothers of newborn infants (Amitai et al., 2004). Their findings reported that a significant increase in the indices of awareness and knowledge utilization in post-university education (Amitai et al., 2004). This has indicated that educated women are likely to avoid the risk (Amitai et al., 2004). Here, it can be inferred that there may also be a need for further national campaigns to increase awareness in uneducated women in contrast to women with post-university education.
Further, NTD’s were found to be better managed by randomized controlled trials (Cornel et al., 2005). To this end, there were several contrasting nationwide pubic issues concerned with the fortification of foods and supplementation (Cornel et al., 2005). Here, it is reasonable to mention that the impact of education, random studies in understanding the risk has given the policymakers a much deeper analysis of the situation and apply the concept in a different policy-making theory. Therefore, the protective role of folic acid has gained much emphasis (Cornel et al., 2005).
On the other hand, the adverse effects likely to be associated are masking of Vitamin B-12 deficiency, an increase the chances of twinning, and improving the occurrence rate of pre-existing malignant neoplasms (Cornel et al., 2005). This opposing effect of folic acid has further led public health policymakers to manage the NTD’s with many difficulties (Cornel et al., 2005). This scientific dilemma needs to be addressed by undertaking a technological and meta-analysis study (Cornel et al., 2005).
However, it was reported that awareness programs are not improving the recommendations in some regions like the Mediterranean area (Coll et al., 2004). The researchers have made a retrospective study on women who delivered previously. It was found that most women were unaware of the folic acid recommendation to avoid the risk of NTD’s (Coll et al., 2004). This could indicate that an inefficient intervention to impede the risk of NTD’s.
Therefore, the utility of a technological and meta-analysis study, retrospective analysis, may indicate a different policymaking theory with regard to the relevance of the study
Your recommendations for the policy response
Given the above information, certain recommendations are that there is a need for preconception counseling to make aware of the protective effects of folic acid (Coll et al., 2004).
Negligence could interfere and impede the progress of an intervention program This needs to be circumvented. In a study, researchers have described the negligence shown by most women in following the recommendations (Eichholzer, Tönz, & Zimmermann, 2006). It was reported that in European countries there was hardly any evidence of the decline in NTD’s (Eichholzer, Tönz, & Zimmermann, 2006). Here, most of the neglected women are those with low education standards, young people, and unplanned pregnancies (Eichholzer, Tönz, & Zimmermann, 2006). Mandatory fortification has improved the folate and homocysteine status in countries like the USA, Canada, and Chile.
Therefore, there is a need of implementing reliable public-health strategies to lessen the incidence of NTD’s (Eichholzer, Tönz, & Zimmermann, 2006).In contrast, the trend is different in Australia. Here, much emphasis should be given to the voluntary fortification of a diet with folic acid (Oddy et al., 2007). A thorough study of available research evidence on the protective role of folic acid in lessening the incidence of NTD’s should be made by the health care professionals and policymakers to control the incidence rates. Most women were almost aware of the connection between NTD’s and folic acid (Oddy et al., 2007).
It was described that there were nearly 80% of women have taken a folic acid-enriched diet. Hence, there were implications that the fortification of staple foods could be implemented in other parts of the world. (Oddy et al., 2007) The above information has been indicated.Further, to overcome the pitfalls in the efficient management of NTDs with dietary folic acid, certain recommendations and strategies need to be followed in an evidence-based practice manner. Thorough monitoring of NTD status across various nations would help in understanding the problems concerned with folic acid intake. Laboratory findings need efficient data to strengthen results, especially the demographic and socio-economic conditions of women in both developed and developing countries.
References
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- Amitai, Y., Fisher, N., Haringman, M., Meiraz, H., Baram, N., Leventhal, A.2004. Increased awareness, knowledge and utilization of preconceptional folic acid in Israel following a national campaign. Prev Med, 39(4), pp. 731-7.
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