Pregnancy : Folic Acid Awareness Before You're Pregnant

Molly Rosbach, Yakima Herald-Republic, Wash.

In the Yakima Valley, resources are plentiful for teens and low-income women who find themselves pregnant without a plan.

For a county with the third-highest teen birth rate in the state, providers say access to information and care during pregnancy is crucial.

But they also say some women still fall through the cracks.

That's what makes the recent announcement by state and local public health officials about a sudden spike in a fatal birth defect in the county last year so troubling to medical professionals involved in maternal care and prenatal health. Without adequate health information, women are at higher risk of missing out on important prenatal and even pre-conception care that could help avoid such defects.

"Because the state will provide insurance coverage for most low-income women who are pregnant, almost everybody who needs care can get it. So that's a good thing," said Dr. Anita Showalter, who was an obstetrician at the Yakima Valley Farm Workers Clinic for four years before joining the faculty at Pacific Northwest University of Health Sciences, where she's also assistant dean of clinical sciences.

"When somebody slips through the cracks, it's generally because they didn't avail themselves to those things that are there for them," or because of barriers to access such as lack of transportation, Showalter said.

Citing state Department of Health statistics, the Yakima Health District issued a news release Jan. 30 announcing that eight cases of anencephaly had occurred in Yakima County in 2012. Typically, public health officials expect only one all year. The state has begun an investigation to find if the number is a trend or a random spike.

Anencephaly, which is uniformly fatal, is caused when the protective neural tube doesn't close completely around the spine at the base of the brain. The result is the absence of a large part of the brain and skull.

The most conclusive studies show a direct link between neural tube defects and a lack of folic acid, which is found in leafy green vegetables, citrus fruits and legumes, among other foods. Taking vitamins with folic acid is an easy way to help prevent anencephaly -- if women know to do so.

The tricky thing, experts say, is that anencephaly occurs by the fourth or sixth week of pregnancy, before many women may even know they're pregnant. So providers recommend that all women of childbearing age take at least 0.4 miligrams of folic acid daily.

"You can't wait until you go, 'Oh, I'm pregnant,' and then take (folic acid); it's too late," said Susie Ball, genetic counselor at Yakima Valley Memorial Hospital's maternal health office. For effective prevention, "You have to do it all the time."

Ball meets with families when any kind of birth defect is detected in prenatal screening. With anencephaly, there is a genetic predisposition for the defect -- women who have it in their families are at higher risk -- but no test before conception to determine if the parents have that predisposition. There also seems to be a slightly higher predisposition for the condition among Hispanics, Ball said.

The high rate of diabetes in the Valley is concerning, too, as the disease puts pregnant women at higher risk for birth defects of any kind, Ball said.

A healthy diet that includes folic acid is sometimes harder for low-income women, Showalter said.

"Where we run into problems is the people who are doing a lot of fast food or already-prepared food that alters that mix," she said, adding that families who do a lot of home-cooking have a better chance of having a balanced diet.

Diet is a problem for teen moms too, says Heather Bulfinch, who teaches teen moms at Davis High School as part of Yakima's program for student parents. Teens don't always worry much about what they're eating, she said, so nutrition is a big part of their instruction.

"Folic acid is not in Hot Cheetos," Bulfinch said. "We revisit nutrition multiple times throughout our curriculum; you need reminders."

Lori Gibbons runs Memorial's childbirth education program and says teens have a sense of invincibility. "They don't think anything will happen to them," she said, so they may not think they need to take folic acid.

Both health educators and providers say they discuss folic acid and prenatal vitamins as early as possible when pregnant women first seek care.

In its investigation, the Health Department will also look at environmental factors that could have contributed to the increase in the defect last year. For example, medical doctors from the state Health Department and the Yakima Health District say a few small studies have shown an increased rate of anencephaly in women who drink from private well water where nitrates exceed the federal safety limit.

"The first thing I ask, because the demographics of our city haven't changed significantly ... is what environmental thing might have happened that could've been a factor that we don't know or understand yet?" Showalter said. There are medications, including some antibiotics, that can block absorption of folic acid in the body, and she wonders if there might be chemicals present in the Valley that could do the same thing.

Studies show that anencephaly is often caused by multiple factors, so providers and health officials have to be aware of all possibilities. And there's a chance that Yakima's high number in 2012 was just a fluke.

"It's such a detective game because there are different things that can cause it, and sometimes in the end, we don't know," Showalter said. "It comes and it goes and you pray it doesn't happen again."

--Molly Rosbach can be reached at 509-577-7728 or

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