CLAIM:
Not taking folic acid during pregnancy can lead to severe developmental issues in children, including microcephaly, which may also be linked to TORCH infections, and it should ideally be taken three months before conception or immediately after a positive pregnancy test.
FACT:
Folic acid is essential for early foetal development, particularly for preventing neural tube defects like spina bifida and anencephaly. Experts point out that, while folic acid deficiency may occasionally contribute to microcephaly, most cases are linked to maternal infections or genetic factors, and routine supplementation before and during early pregnancy significantly reduces the risk of birth defects.
In a viral reel posted by Dr Samra Khan, an obstetrician-gynaecologist with over 1.7 lakh followers on Instagram, the doctor highlights the importance of folic acid during pregnancy through the example of a visibly affected child.
In the video, she is seen holding a one-year-old baby with a small head and explains that the child is “not normal” and suffers from severe developmental issues. She adds that the family has three children, and the eldest, now five years old, “cannot walk, cannot go to the washroom on his own, is mentally retarded, and cannot even hear.”
Pointing to the infant in her arms, Dr Khan says, “This baby is one-year-old. You can see how small his head is. This is called a microcephalic baby.” She further explains that the abnormal head shape and poor brain development can occur when the mother does not take folic acid during pregnancy and may also be linked to infections such as TORCH, especially cytomegalovirus. “Folic acid is very important for the growth of the brain and spinal cord,” she says, stressing that it should ideally be taken three months before planning pregnancy or at least from the moment a pregnancy test turns positive.
The reel has triggered widespread discussion online about whether skipping folic acid can truly lead to such severe birth defects and how essential it really is during pregnancy.
What is folic acid?
According to Harvard Medical School, folic acid is a “synthetic form of folate, a B vitamin found naturally in various fruits, vegetables, and legumes." They also highlighted that we need folates to "produce and maintain new cells (in particular, red blood cells) and to keep nerve cells functioning properly." "It also helps prevent DNA changes that may lead to cancer. In the body, folic acid and naturally occurring folate are identical in their actions, but the bioavailability of folic acid is somewhat higher than that of folate," it added.
Is folic acid important during pregnancy?
Folic acid is considered one of the most critical nutrients for women during their childbearing years. A crucial phase of foetal development happens during the first few weeks of pregnancy, often before a woman even realises she is pregnant. During this time, the neural tube forms and later develops into the brain and spinal cord. Without enough folic acid, this structure may not close properly, leading to neural tube defects (NTDs).
Two of the most common NTDs are spina bifida, where part of the spinal cord develops outside the body, and anencephaly, where large parts of the brain and skull do not form. Research has consistently shown that taking folic acid one month before conception and during the first trimester significantly lowers the risk of these defects. Because natural dietary folate is often insufficient, many countries, including the US and Australia, add folic acid to many grain products, a policy credited with reducing rates of neural tube defects.
Leading health agencies such as the World Health Organization and the Centers for Disease Control and Prevention recommend folic acid supplementation for women of childbearing age.
A 2023 review conducted for the US Preventive Services Task Force, which analysed data from more than 12 observational studies covering over 12.4 lakh pregnancies, reaffirmed the benefits of folic acid in pregnancy. The review assessed studies published between 2015 and 2021 and found that folic acid supplementation before and during early pregnancy significantly reduced the risk of neural tube defects.
One cohort study cited in the review found that women who consumed folic acid before pregnancy had a lower risk of having a baby with a neural tube defect, with an adjusted relative risk (aRR) of 0.54. Those who took folic acid during pregnancy also showed a reduced risk (aRR 0.62). The strongest protective effect was seen among women who took folic acid both before and during pregnancy, with an adjusted relative risk of 0.49, indicating nearly a 50 pc reduction in risk.
The review concluded that, “New evidence from observational studies provided additional evidence of the benefit of folic acid supplementation for preventing neural tube defects and no evidence of harms related to multiple gestation, autism, or maternal cancer. The new evidence was consistent with previously reviewed evidence on benefits and harms.”
Dr Abha Majumdar, director and head of the centre for IVF & human reproduction at Sir Ganga Ram Hospital, explained that folic acid plays a fundamental role in early foetal development. She said that folic acid is “an essential vitamin which helps new cells and DNA to form in the very early weeks of pregnancy,” and is especially important for protecting against neural tube defects.
She added that defects of the brain and spine “can be prevented if they are due to a deficiency of folic acid.” Dr Majumdar noted that folic acid is derived from dietary folates found in green leafy vegetables, but pointed out that “sometimes there is a dietary deficiency, and sometimes the conversion of folic acid into its active form does not happen due to enzyme deficiencies,” both of which can lead to developmental problems. She emphasised that these critical changes occur within the first 11 to 12 weeks of pregnancy.
Dr Majumdar, who brings over 45 years of experience, explained that TORCH infections are a separate group of conditions, where T stands for toxoplasmosis, R for rubella, C for cytomegalovirus, H for herpes, and O for other infections. She clarified that these infections typically affect the mother for the first time in life, and only in a small percentage of cases do they get transmitted to the baby. “If the baby gets infected, then only the infection affects the development and can cause multiple congenital anomalies,” she said. However, she added that if the mother has had a prior infection and already has antibodies, reinfection usually does not cause severe problems, and in such cases, transmission to the baby is rare.
Does lack of folic acid cause microcephaly?
Microcephaly is a rare neurological condition in which an infant's head is much smaller than the heads of other children of the same age and sex. Sometimes detected at birth, microcephaly often occurs when there is a problem with brain development in the womb or when the brain stops growing after birth.
A 2023 genetic study on cerebral folate deficiency (CFD) highlighted that some cases of microcephaly occur due to genetic defects in folate transport, not due to dietary folate deficiency alone. The study described two siblings with drug-resistant seizures, neuroregression, and microcephaly caused by a mutation in the FOLR1 gene, which prevents folate from reaching the brain despite normal blood folate levels.
The researchers noted that, “Patients showed low 5-methyltetrahydrofolate levels in cerebrospinal fluid despite normal serum folate,” and treatment with folinic acid improved seizures and spasticity. This shows that some microcephaly cases are genetic and cannot be prevented simply by routine folic acid intake.
Dr Majumdar explained that microcephaly is more commonly linked to maternal infections rather than folic acid deficiency alone. Speaking about TORCH infections, she said these usually cause harm “when the mother gets the infection for the first time during the critical period of organ formation.” She added that, in most cases, “many maternal infections do not get transmitted to the baby at all,” and even when they cross the placenta, the amount transmitted is often too small to cause disease.
"Microcephaly is therefore more often infection-related,” she noted.
Dr Majumdar further clarified that folic acid deficiency is more directly associated with neural tube defects involving the brain and spinal cord, such as spina bifida and anencephaly, which are formation defects. “These types of defects happen due to folic acid deficiency,” she said. While she acknowledged that folic acid deficiency may occasionally be linked to microcephaly, she stressed that infections remain the more common cause. She also pointed out that other defects linked to folic acid deficiency include cleft lip and cleft palate.
Recommendations for folic acid consumption
According to WHO, “All women, from the moment they begin trying to conceive until 12 weeks of gestation, should take a folic acid supplement (400 μg folic acid daily). Women who have had a foetus diagnosed as affected by a neural tube defect or have given birth to a baby with a neural tube defect should receive information on the risk of recurrence; be advised on the protective effect of periconceptional folic acid supplementation; be offered high-dose supplementation (5 mg folic acid daily); and be advised to increase their food intake of folate.”
Dr Majumdar explained that all nutritional deficiencies can affect foetal development, but folic acid plays a particularly critical role during the first few weeks of pregnancy. She noted, “Folic acid is an essential component that helps in DNA multiplication and cell multiplication. So, whether you take it before or during pregnancy depends on your nutritional status.”
She highlighted that “women with a balanced diet rich in leafy green vegetables may not need to start supplementation months before conception. However, if the nutritional status is poor, it is very important to take folic acid before pregnancy because by the time you realise you are pregnant, four or five weeks of organogenesis may have already elapsed, and deficiency can affect the baby’s development.”
Special consideration is needed for women on certain medications. “Women on antiepileptic medicines need a higher dose of folic acid and should continue it throughout pregnancy because these medicines deplete folic acid from the body. This is very important, and doctors should ensure epileptic patients are advised to continue folic acid across pregnancy,” she advised.
This story is done in collaboration with First Check, which is the health journalism vertical of DataLEADS.
