Folic acid

(Date of issue: August 2013. Version: 1)

This factsheet has been written for members of the public by the UK Teratology Information Service (UKTIS). UKTIS is a not-for-profit organisation funded by Public Health England on behalf of UK Health Departments. UKTIS has been providing scientific information to health care providers since 1983 on the effects that medicines, recreational drugs and chemicals may have on the developing baby during pregnancy.

What is it?

Folic acid is a man-made form of vitamin B9 (folate). Folate is essential for the production of blood cells and DNA. 

Why do I need to take folic acid during pregnancy?

Women require up to 10 times more folate during pregnancy to support the development of the baby. Low folate levels in the mother have been strongly linked to defects of the baby’s brain, skull, and spinal cord, known as ‘neural tube defects’, and possibly to some other birth defects, including cleft lip or palate. It is therefore recommended that all pregnant women, and those planning a pregnancy, take a folic acid supplement until at least the 12th week of pregnancy.

How much folic acid is recommended during pregnancy?

Most pregnancy folic acid supplements and multivitamins contain at least 400 micrograms of folic acid in each tablet. This is the recommended daily dose for most women who are likely to have normal folate levels.

Some women may have low folate levels because of a medicine that they are taking or because of their health. For example, certain epilepsy medicines, and being diabetic or obese, have been linked to low folate levels. In these situations pregnant women, or those considering a pregnancy, are advised to take a higher daily dose of 5 milligrams folic acid. High dose folic acid tablets need to be prescribed by a doctor. This higher dose is also advised for women who have previously conceived or given birth to a child with a neural tube defect, or have a family history of neural tube defects, or certain other birth defects (see below).

There are no known harmful effects on the development of the baby from taking 400 micrograms or 5 milligrams of folic acid daily during pregnancy.

How do we know that taking folic acid during pregnancy prevents birth defects?

A baby’s body and most internal organs are formed during the first 12 weeks of pregnancy. Many studies have shown that folic acid is very important for this to happen normally. 

Neural tube defects
There is excellent evidence from many large scientific studies that neural tube defects can be caused by low folate levels. Neural tube defects affecting the spine include spina bifida, which can range in severity from a harmless dimple in the skin of the lower spine, to openings in the spinal skin, muscle, bone, and nerves that can cause paralysis and incontinence. Neural tube defects affecting the skull bones and brain usually cause stillbirth or the baby to die shortly after birth and are often detected by antenatal scan.

Because the baby’s neural tube starts forming in the first four weeks of pregnancy (before the first missed period) it is best to start taking folic acid before trying to become pregnant, or as soon as a pregnancy is suspected if it has not been planned. In the UK and Ireland in the 1980s, before it was recommended that pregnant women take a folic acid supplement, about one in every 200 pregnancies resulted in a baby with a neural tube defect. Taking folic acid in early pregnancy reduces this risk to less than one in 400. Taking folic acid before and during pregnancy is particularly important for women who have previously conceived or given birth to a baby with a neural tube defect.

There is not yet any scientific evidence to show whether higher dose folic acid (5 milligrams) is any better than the standard dose (400 micrograms) at reducing the chance of neural tube defects in babies of women with low folate levels due to, for example, obesity, diabetes, or being on certain medicines. It is also not known whether the neural tube defects that have been linked to taking medicines like sodium valproate can be prevented by taking folic acid. However, until more scientific information is available, high dose folic acid is advised in pregnant women who are at risk of having low folate levels or who are taking certain medicines.

Cleft lip and palate
Some studies have suggested that taking folic acid during early pregnancy may decrease the risk of cleft lip and/or palate in the baby, but other studies have not shown this effect. It is possible that only some types of cleft lip and/or palate are linked to low folate levels. More research on this subject is required.

Defects of the urinary system
One study has shown that babies of women who took folic acid supplements were less likely to have a birth defect of the urinary system (bladder, kidneys) than babies of women who didn’t. Further research is required to prove this.

Does taking folic acid during pregnancy affect my risk of miscarriage, stillbirth, preterm birth, or having a low birth weight baby?

Although some studies suggest that these pregnancy problems are less likely to occur in women who take folic acid supplementation, most studies have shown no difference in the rates of these pregnancy outcomes between women taking folic acid during pregnancy and those not taking folic acid. There is no scientific proof of any harmful effects of folic acid on the fetus.

Is there any evidence that taking folic acid during pregnancy protects against learning and behavioural problems in the child?

A baby’s brain continues to develop right up until the end of pregnancy. It is therefore possible that taking certain medicines at any stage of pregnancy could have a lasting effect on a child’s learning or behaviour.

One study found no difference in learning and behaviour of children whose mothers took folic acid supplements during pregnancy and children whose mothers didn’t. However, another study showed that children whose mothers took folic acid during pregnancy were about half as likely to develop autism compared to children who were not exposed to folic acid while in the womb.

It should, however, be noted that it is very difficult to study any effect of taking a medicine during pregnancy on the learning and development of the child and much more research is required before we can say whether or not taking folic acid during pregnancy protects a baby against learning and behavioural problems.

Will my baby need extra monitoring if I haven’t taken folic acid?

Most women will be offered a scan at around 20 weeks of pregnancy to look for birth defects as part of their routine antenatal care. Not taking folic acid during pregnancy would not normally require extra monitoring of your baby. However, if you are thought to be at high risk of folate deficiency, or have a family history of neural tube defects, your doctor may advise a more detailed ultrasound scan or further tests.

Who can I talk to if I have questions?

If you have any questions regarding the information in this leaflet please discuss them with your health care provider. They can access more detailed medical and scientific information from www.uktis.org.  

General information 

Up to 1 out of every 5 pregnancies ends in a miscarriage, and 1 in 40 babies are born with a birth defect. These are referred to as the background population risks.  They describe the chance of these events happening for any pregnancy before taking factors such as the mother’s health during pregnancy, her lifestyle, medicines she takes and the genetic make up of her and the baby’s father into account.

Medicines use in pregnancy

Most medicines used by the mother will cross the placenta and reach the baby. Sometimes this may have beneficial effects for the baby.  There are, however, some medicines that can harm a baby’s normal development.  How a medicine affects a baby may depend on the stage of pregnancy when the medicine is taken. If you are on regular medication you should discuss these effects with your doctor/health care team before becoming pregnant.

If a new medicine is suggested for you during pregnancy, please ensure the doctor or health care professional treating you is aware of your pregnancy.

When deciding whether or not to use a medicine in pregnancy you need to weigh up how the medicine might improve your and/or your unborn baby’s health against any possible problems that the drug may cause. Our bumps leaflets are written to provide you with a summary of what is known about use of a specific medicine in pregnancy so that you can decide together with your health care provider what is best for you and your baby.   

Every pregnancy is unique. The decision to start, stop, continue or change a prescribed medicine before or during pregnancy should be made in consultation with your health care provider. It is very helpful if you can record all your medication taken in pregnancy in your hand held maternity records.

   

www.medicinesinpregnancy.org

Disclaimer: This information is not intended to replace the individual care and advice of your health care provider. New information is continually becoming available. Whilst every effort will be made to ensure that this information is accurate and up to date at the time of publication, we cannot cover every eventuality and the information providers cannot be held responsible for any adverse outcomes following decisions made on the basis of this information. We strongly advise that printouts should NOT be kept for any length of time, or for “future reference” as they can rapidly become out of date.

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