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Pre-Conceptional Vitamin Supplements and the Politics of Risk Reduction Q

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Pre-Conceptional Vitamin Supplements and the Politics of Risk Reduction Q View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Studies in History and Philosophy of Biological and Biomedical Sciences 47 (2014) 278–289 Contents lists available at ScienceDirect Studies in History and Philosophy of Biological and Biomedical Sciences journal homepage: www.elsevier.com/locate/shpsc Making birth defects ‘preventable’: Pre-conceptional vitamin supplements and the politics of risk reduction q Salim Al-Gailani Department of History and Philosophy of Science, University of Cambridge, Free School Lane, Cambridge CB2 3RH, UK article info abstract Article history: Since the mid-1990s, governments and health organizations around the world have adopted policies Available online 21 November 2013 designed to increase women’s intake of the B-vitamin ‘folic acid’ before and during the first weeks of pregnancy. Building on initial clinical research in the United Kingdom, folic acid supplementation has Keywords: been shown to lower the incidence of neural tube defects (NTDs). Recent debate has focused principally Folic acid on the need for mandatory fortification of grain products with this vitamin. This article takes a longer Vitamin supplements view, tracing the transformation of folic acid from a routine prenatal supplement to reduce the risk of Pre-conception anaemia to a routine ‘pre-conceptional’ supplement to ‘prevent’ birth defects. Understood in the 1950s Public health in relation to social problems of poverty and malnutrition, NTDs were by the end of the century more Clinical trials Risk likely to be attributed to individual failings. This transition was closely associated with a second. Folic acid supplements were initially prescribed to ‘high-risk’ women who had previously borne a child with a NTD. By the mid-1990s, they were recommended for all women of childbearing age. The acceptance of folic acid as a ‘risk-reducing drug’ both relied upon and helped to advance the development of preventive and clinical practices concerned with women’s health before pregnancy. Ó 2013 The Author. Published by Elsevier Ltd. All rights reserved. When citing this paper, please use the full journal title Studies in History and Philosophy of Biological and Biomedical Sciences 1. Introduction: folic acid and risk reduction persuade women to take a daily supplement of folic acid in order to ‘help [their] baby develop a healthy brain and body’.1 At least Since the mid-1990s, governments and health organizations for those women for whom pregnancy is planned, the decision to around the world have adopted policies designed to increase wo- replace the daily ritual of swallowing a contraceptive pill with a vita- men’s dietary intake of ‘folic acid’ before and during pregnancy min supplement has come to signify the transition to ‘hoped-for in order to reduce the risk of having a baby with a defect of the motherhood’ and a more highly disciplined regime of consumption brain and/or spinal cord. Folic acid is the synthetic form of folate, (Landsman, 2004, pp. 105–106; Taylor, 2008, p. 127). This article a B-group vitamin naturally present in many foodstuffs, particu- offers the first history of how taking a folic acid supplement became larly leafy green vegetables, and presumed essential for cell growth both a common part of the experience of pregnancy and a drug that and development. Neural tube defects (NTDs) such as spina bifida promises to reduce individual risk. are among the most common congenital malformations and a sig- Policies to encourage folic acid consumption are characteristic nificant cause of neonatal mortality worldwide (Blencowe, of the emphasis on risk prevention that came to dominate the Cousens, Modell, & Lawn, 2010). The proposed link between management of health and disease in developed countries after dietary folate deficiency and birth defects has convinced several 1945 (Berridge, 1999; Brandt, 1997; Rothstein, 2003). They are also countries to fortify grain products with folic acid (Semba, 2006, a symptom of a broader trend in which the risk to the unborn fetus p. 176). Others have relied on health education strategies to has displaced the risk of maternal mortality as the main focus of q This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. E-mail address: [email protected] 1 According to the UK National Health Service online Information Service for Parents, ‘Start 4 Life’: http://www.nhs.uk/start4life/Pages/vitamin-supplements-folic-acid- pregnant.aspx (accessed 15 December 2012). 1369-8486/$ - see front matter Ó 2013 The Author. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.shpsc.2013.10.009 S. Al-Gailani / Studies in History and Philosophy of Biological and Biomedical Sciences 47 (2014) 278–289 279 the medical interventions in pregnancy and childbirth (Lupton, and uncertainty to claim a stake in pre-conceptional vitamin sup- 2012). Increased emphasis on the management of risk in childbirth plements as a means of preventing NTDs. since World War Two has justified the expansion of obstetric sur- veillance ever earlier into pregnancy (Arney, 1982, p. 143; Weir, 2. From Marmite to folic acid: vitamin supplements in 2006). However, risk prevention strategies have often developed pregnancy in piecemeal fashion and cannot be attributed solely to profes- sional aspirations to extend the scope of obstetric control. Studying Dietary prescriptions had long been a staple of informal health the long-term trajectory of folic acid helps to recover the complex guidance to expectant and nursing mothers before rising concern medical, social and political contingencies that helped to drive this about infant mortality around 1900 consolidated the status of shift. nutritional advice in voluntary and statutory systems of maternal Historians have long recognized that ‘risk-reducing’ interven- and child welfare (Cody, 2011; Dwork, 1987; Oakley, 1984). In tions have not only enhanced the medical scrutiny of subjectively the following decades, pregnant women were identified as impor- healthy populations, but also constituted novel categories of pa- tant beneficiaries of the new knowledge of vitamins, deployed by tients and disease states. Commercial promotion, professional not only medical practitioners and public health workers, but also enthusiasm and consumer demand for preventive medical inter- charitable, educational and campaigning organizations. Manufac- ventions in chronic conditions such as cancer and diabetes have turers of ‘nutrient-rich’ proprietary foods such as Marmite, made blurred the boundary between statistical risk and experienced ill- from yeast extract, Stork margarine and the stabilized wheatgerm ness, creating both symptomless ‘pre-patients’ and treatments for Bemax stressed that ‘vitamin need’ was ‘especially important in ‘proto-diseases’ (Aronowitz, 2009; Greene, 2007; Löwy, 2010; the case of the expectant mother, as any Maternity or Child Wel- Rosenberg, 2007, p. 27; Valier, 2012). In a similar fashion, this arti- fare centre will confirm’. The marketing of vitamin supplements cle suggests, the acceptance of folic acid as a ‘risk-reducing drug’ as ‘indispensible’ for pregnant women, ‘for their own sake and that both relied upon and helped to advance the development of a novel of the child’, extended a long tradition of emphasizing family nutri- set of preventive and clinical practices concerned with women’s tion as mothers’ responsibility and duty (Apple, 1995; 1996, p. health before pregnancy. Originating around 1980, strategies to 182).3 promote both ‘pre-conception’ or ‘pre-pregnancy’ care and ‘pre- Many interwar health workers were convinced of the value of conceptional’ vitamin supplementation evolved in close relation Marmite and other vitamin-rich preparations in reducing the risk and were mutually reinforcing. of death in childbirth. By distributing Marmite and other supple- What kind of intervention is pre-conceptional vitamin supple- ments to working-class expectant mothers in England and Wales, mentation? A complete answer would require an international the voluntary National Birthday Trust Fund and the People’s Lea- and cross-disciplinary history over at least the last half-century. gue of Health could combine relief with research into the impact Research on folic acid was—and remains—global and multi-sited; of prenatal nutrition on maternal mortality (People’s League of individual clinical trials could span several countries, as we shall Health, 1946; Williams, 1997). This conviction informed official see. Yet even as the postwar globalization and homogenization of wartime nutrition policies. The supply of free or cheap vitamin A biomedical knowledge helped constitute folic acid as a risk-reduc- and D tablets, milk, orange juice and cod liver oil to expectant ing drug, research into this vitamin and strategies to promote its mothers and children through the wartime vitamin welfare consumption were also local initiatives, producing local responses. scheme, with their perceived role in the decline of maternal mor- Expert disagreement over mandatory folic acid fortification has tality, consolidated the importance of dietary supplements in preg- generated considerable international policy controversy over such nancy. At the war’s end, the Ministry of Food could declare that the issues as individual versus social responsibility, medical
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