It is nice to see the Minister of State in the House, having met him earlier today at the conference on health for older women in UCD. However, I now want to talk about health services for younger women.
Some of the most devastating congenital abnormalities in babies involve neural tube defects. The neural tube is that part of the embryo which develops into the brain, the spinal cord and the nervous system. At an early developmental stage, within a few weeks of conception, abnormalities in the development of the neural tube can occur leading to anencaphaly if the abnormality is at the anterior end of the tube and to spina bifida if the abnormality occurs at the posterior end. The former is incompatible with life outside the womb and the latter, if not leading to a similar fate for the newborn child, means serious neurological problems in many cases for a child who survives.
Unfortunately, Ireland has a high incidence of children born with neural tube defects and at one stage we had the highest incidence in Europe. About 70 to 80 children with anencephaly or spina bifida are born each year in Ireland. Worse still, a woman may have several affected children. It can run in families and many babies may be lost as miscarriages. This, naturally, has caused enormous distress to the parents and families of these children.
Over the past 20 years Irish and international researchers have made Trojan efforts to elucidate the causes of this problem. It rapidly became evident there was a nutritional element because lower socio-economic groups had a higher incidence of problems. Nutritional problems are often serious in this section of the community. Research showed that low serum folate levels were associated with the development of neural tube defects, particularly if these were present at the time of conception and in the early weeks of the development of the embryo.
Great efforts have been made to encourage women who hope to become pregnant to take an added amount of folic acid in tablet form to prevent such problems developing. If both prospective parents took the folates it would probably be even better. The Department of Health in the United Kingdom and the Department of Health and Human Services in the United States were the first to issue recommendations on the use of folic acid to prevent neural tube defects. The recommendations relate to prevention of occurrent — first time — and recurrent NTDs and similar recommendations have been adopted by other national health authorities.
The main points in these recommendations were as follows: to prevent NTD recurrence in the offspring of women or men with spina bifida or encephalocele themselves, or with a history of a previous child with NTD; such women and men should be counselled about the increased risk in subsequent pregnancies and about the protective effect of supplementation with folic acid; women with a previously affected pregnancy should, unless contra-indicated, be advised to take 4.0 mg of folic acid daily from at least four weeks before conception until the end of the third month of pregnancy. In countries where a 5.0 mg rather than a 4.0 mg preparation is available, the former can be used but the lower 4.0 mg dose should be used as soon as this preparation becomes available.
The 4.0 mg dose should be taken only under the supervision of a doctor for two main reasons. First, giving high doses of folic acid can complicate the diagnosis of vitamin B12 deficiency. Second, epileptic women on anti-convulsant therapy require individual counselling before starting folic acid. The folic acid dose should be obtained from pills containing only folic acid and not from multi-vitamin preparations because of the danger of taking harmful levels of vitamins A and D. I am glad to say that such tablets are produced in Ireland by Clonmel Chemicals, among others.
For the prevention of occurrence of NTDs the United States public health service recommends that all women capable of becoming pregnant consume 0.4 mg of folic acid per day and that total folate consumption should not be more than 1.0 mg per day to avoid the possible risks of high intake. The United Kingdom expert advisory group recommends that women should take an extra 0.4mg of folic acid daily from the time they begin trying to conceive until the 12th week of pregnancy. If a woman who has not been taking this additional amount of folic acid suspects that she may have just started a pregnancy, she should begin taking extra folic acid at once and continue until the 12th week of pregnancy.
In practice, however, taking into account that the fact that at least 30 per cent and maybe 50 per cent of pregnancies are unplanned, any such campaign will not cover enough of the population when it is recognised that those young women in the lower socio-economic groups, who have the most likelihood of having a child with a neural tube defect, are the least likely to take additional folate. As a medical doctor, the Minister of State will be aware that efforts have been made to improve this situation here and in Britain with little success. Eating folate rich food, such as broccoli, frequently does not raise the blood folate levels sufficiently. Another route has to be considered.
In January 1998 the Legislature of the United States of America will introduce a law to fortify flour for the general production of bread and confectionery with folates. It is now known that it is a genetic deficiency in the katabolism of homocysteine allowing it to build up to high levels. This is a major factor in this problem. Folic acid is a cofactor in an important enzymatic reaction in the metabolism of homocysteine. We in Ireland have about a 10 per cent incidence in the population of the genetic defect which allows high levels of homocysteine to develop if folic acid intake is deficient. Some countries, such as Italy, may have a 15 per cent incidence and other countries, such as South Africa, a lower incidence.
This is not just a problem of homocysteine and neural tube defects, because high levels of homocysteine may also be important in the development of cardiovascular disease. It may eventually be found that reducing blood levels of homocysteine lowers instances of cardiovascular disease, which would be important to men. We must take this into account when considering the fortification of flour with folates. Over the next few years further research may elucidate the importance of folates here.
The question of changing the diet of a population by the fortification of food or water is a very emotive issue, and Members will remember the debate on the fluoridation of water. Looking at the beneficial effects that has had on the teeth of children, it is hard to see that debate as being worthwhile. However, if the evidence is there that the overall good, especially of unborn children, is improved by the addition of folates, the Minister must consider acting as soon as possible. The Food Safety Advisory Board has a report which explains all I have said in much greater detail and far more eloquently. I hope it has been forwarded to the Minister.
Some flour naturally must be excluded so that those who wish to make bread with unfortified flour can do so, but so much of our food is fortified with minerals and vitamins which have obviously helped raise our nutritional standards, reduce levels of anaemia and other health problems that we need to move now on folates.
