n 2012 the World Health Organization’s Global Malaria Program reconfirmed the use of intermittent preventive treatment for pregnant women (IPTp) using sulfadoxine-pyrimethamine (SP). IPTp now may be given at each antenatal care (ANC) visit after the first trimester as long as it is a month since the last dose.
Countries have been moving forward in reviewing and adapting/adopting this guidance where appropriate. One of the key challenges countries have faced is what to do about folic acid, which is given concurrently with IPTp as part of focused ANC. Specifically the guidance states … WHO recommends the administration of folic acid at a dose of 0.4 mg daily; this dose may be safely used in conjunction with SP. Folic acid at a daily dose equal or above 5 mg should not be given together with SP as this counteracts its efficacy as an antimalarial.
This new low dose formulation of folic acid requires accessible and affordable supplies made available through a country’s pharmaceutical procurement system. Manufacturers would need to adjust, and national food and drug approval agencies would need to register the product(s).
All this worry may in fact be a case of closing the barn door after the horses have escaped. Since in many countries women do not register for antenatal care until well into their second trimester, the benefits of folic acid supplementation may in fact me missed. A broader view of the health and nutrition of women of reproductive age is needed, not just the narrow focus of giving folic acid as part of ANC.
The online encyclopedia of Medline explains that “There is good evidence that folic acid can help reduce the risk of certain birth defects (spina bifida and anencephaly). Women who are pregnant or planning to become pregnant should take at least 400 micrograms (mcg) of a folic acid supplement every day.” Let’s look at the term “planning to become pregnant.” This means that women of reproductive age (WRA) who are interested in having children need to ensure that taking folic acid. Since many pregnancies are not “planned” this means folic acid should be a regular part of their lives.
How can this be achieved? First, while it may not be practical, WRA could take regular folic acid tablets. A variety of health and social programs, including secondary schools for those who attend, may be venues to try distribution of supplements. Secondly there are food sources, and thirdly there could be fortification of commercial foods with folic acid.
Again the Medline encyclopedia informs us that, “Folate occurs naturally in the following foods: dark green leafy vegetables, dried beans and peas (legumes), and citrus fruits and juices.” These items are often available in malaria endemic countries and part of a normal diet. Of course, as the American Journal of Clinical Nutrition points out, “Naturally occurring seasonal variations in food consumption patterns have a profound effect” on the availability, cost and use of these food sources.
While commercial food fortification is common in industrialized countries, IRIN also points out that, “use local manufacturers and commercial distribution systems to reach undernourished children in Nigeria, Ghana and Tanzania. All three countries have mandatory fortification of wheat flour with iron and zinc.” Why not add folic acid? Researchers in Kenya found that “Locally available indigenous foods can be used in the formulation of acceptable, low-cost, shelf-stable, nutritious supplementary foods for vulnerable groups,” including folic acid fortification.
We should now focus our attention of the folic acid needs of WRA generally. We must plan for the three possible interventions mentioned above as appropriate to each country and as an ongoing effort to ensure women’s overall health and nutrition. If we succeed, women in malaria endemic countries will enter pregnancy with a strong foundation of folic acid supplementation and not have to depend solely on tablets during the short window when they attend ANC.