Model Answer

Spina Bifida is a preventable neural tube defect that results from incomplete closure of the spinal cord during early fetal development, often leading to paralysis, hydrocephalus, incontinence, and long-term orthopaedic complications. Despite clear scientific evidence since the early 1990s that pre-conceptional intake of folic acid can prevent more than 70% of cases, India continues to report a high burden—around 25,000 affected children annually, with a prevalence of about 4 per 1,000 births. This stands in sharp contrast to many countries that have reduced prevalence to below 1 per 1,000 through national awareness campaigns and food fortification, highlighting a significant gap in India’s public health strategy.

Role of Pre-Conceptional Folic Acid Supplementation

Folic acid (vitamin B9) plays a critical role in DNA synthesis and cell division, particularly during the first 28 days of pregnancy when the neural tube forms. Since many pregnancies in India are unplanned, reliance on post-conception supplementation alone is insufficient.

Public health significance:

• WHO recommends 400 micrograms of folic acid daily for women of reproductive age.
• Pre-conceptional supplementation has proven to be one of the most cost-effective preventive interventions in maternal and child health.
• It reduces not only Spina Bifida but also other neural tube defects such as anencephaly.

Indian context: While folic acid is included in antenatal care under national programs, the focus remains largely post-pregnancy, missing the critical pre-conception window. Low awareness among adolescents and young women further limits uptake.

Role of Food Fortification in Prevention

Food fortification involves adding essential micronutrients to commonly consumed foods to improve population-level health outcomes. Several countries, including the United States and Canada, have successfully mandated folic acid fortification of staple foods such as wheat flour, leading to a dramatic decline in neural tube defects.

Relevance for India:

• India has a diverse dietary pattern, making a single staple difficult to target.
• Emerging research suggests fortification of universally consumed items such as salt or tea with folic acid and vitamin B12 as a feasible strategy.
• A recent trial indicates that tea fortification could be an effective delivery mechanism without altering consumption behaviour.

Advantages:

• Reaches women before pregnancy, regardless of awareness or healthcare access.
• Economically efficient compared to long-term medical care and rehabilitation of affected individuals.
• Aligns with preventive healthcare and nutrition security goals.

Implementation Challenges

1. Lack of Awareness: Despite three decades of evidence, India lacks a sustained national campaign on neural tube defect prevention.

2. Policy and Regulatory Gaps: Mandatory folic acid fortification has not been adopted at the national level, unlike iodine or iron.

3. Health System Limitations: Inadequate integration of pre-conception care within RMNCH+A programs and weak outreach to adolescents.

4. Socio-cultural Factors: High rates of unplanned pregnancies and limited reproductive health education hinder timely intervention.

Policy Measures and Way Forward

• Launch a national awareness campaign targeting adolescents and women of reproductive age, similar to iodised salt campaigns.
• Mandate food fortification with folic acid and vitamin B12 in widely consumed staples, supported by robust quality control.
• Integrate pre-conception care into existing programs such as Ayushman Bharat and school health initiatives.
• Strengthen inter-sectoral coordination between health, food processing, and education ministries.
• Support research and pilots, such as tea or salt fortification, to develop India-specific solutions.

India’s continued high burden of Spina Bifida reflects not a lack of scientific knowledge but a failure of policy translation and preventive governance. Pre-conceptional folic acid supplementation and food fortification offer proven, affordable, and scalable solutions. A shift from treatment-centric to prevention-centric public health policy, backed by awareness, regulation, and institutional commitment, is essential to reduce avoidable disability and improve maternal and child health outcomes in India.