Folic acid is incredibly important both at the preconception phase, as well as in early pregnancy. This feature was written for the prestigious Dublin ultrasound clinic, Merrion Fetal Health.

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THE IMPORTANCE OF
FOLIC ACID IN PREGNANCY
Plus Our Special Folic Acid Recipes

2. 2
CONTENTS
What is folic acid?
How much folic acid do you need?
What are the benefits?
What happens when you don't take enough?
The Irish context
Who may be at higher risk?
Food that can partner folic acid
supplements
Asparagus & Ricotta Tarts
Halloumi Burgers
Lamb & Lentil Shepherd’s Pie
Pasta Primavera
Vegetable Gratin
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

3. A
FOREWORD
Folic acid plays a vital role in contributing to a
healthy pregnancy, and a healthy baby.
This magazine has been produced by Merrion
Fetal Health - the medically led, midwife
facilitated ultrasound clinic in Dublin, Ireland.
It incorporates the information that you need to
know about folic acid, as well as looking at the
Irish context.
The research references a number of medical
studies which are included in the bibliography.
Merrion Fetal Health has also commissioned a
chef & nutritionist to create a small selection of
folic acid rich recipes for you.

4. 4
1. What is folic acid?
Folic acid, also known as folate, is a B vitamin,
in its synthetic form. Folic acid is significant for
the production of red blood cells and the
development of a baby’s neural tube into the
spinal cord and brain (1).
Folic acid is necessary for producing and repairing DNA. This is the
body’s genetic map and the basic method of building cells. For that rea-
son, folic acid is essential for the rapid cell growth of the placenta and
the development of the baby. (7)
The body requires folic acid to prevent a certain kind of anemia and
some research believes that taking folic acid daily can reduce the risk
of developing pre-eclampsia. This is a multifaceted disorder that can af-
fect the mother’s health as well as the baby’s health. (4)
The CDC (Centres for Disease Control USA) suggests taking folic acid
daily when pregnant and a month prior to becoming pregnant. The
CDC also recommends that any women of a childbearing age begin tak-
ing folic acid daily whether planning pregnancy or not. (10) This is due
to the fact, that more than half of the pregnancies in the United States
are unplanned.

5. A
1. What is folic acid?
Helps Prevents Birth
Defects
Taking this vitamin can help prevent
birth defects that typically occur dur-
ing the first 3-4 weeks of pregnancy.
Having folic acid in the system dur-
ing the early stages of development,
when the baby’s brain and spinal
cord are developing, is essential. One
study proved that women who took
folic acid for a year prior to getting
Decreases Chance Of
Early Delivery
pregnant decreased the chance of
early delivery by 50% or more. (3)
The neural tube begins forming
around three weeks after concep-
tion; this is why it is important to
receive a daily dose of folic acid
prior to conception and during
the first trimester. (4)

6. 6
2. How much folic acid do you need?
A daily supplement of 400 micrograms
(400μg/0.4mg) folic acid as recommended prior
to conception and for the first 12 weeks of
pregnancy, has been shown to help prevent
neural tube defects (NTD‟s) (FSAI, 2006). (15)
The above data is relevant to the majority of women, but there are
some exceptions, such as when there is a family history of either neu-
ral tube defects (NTDs) or pre-existing diabetes. Women who fall into
these categories will be recommended a higher dose both before con-
ception and during the first trimester.
There is medical evidence that suggests that obese women can also
benefit from a higher dose of folic acid during these periods.
Please note however, that higher dosages must be administered with
care and only by your healhtcare provider.
The March of Dimes, The U.S. Public Health Service, and the American
College of Obstetricians and Gynecologists (ACOG) strongly suggest that
any woman of childbearing age, whether pregnant or not, take at least
400 mcg of folic acid daily. (4)

7. A
2. How much folic acid do you need?
Pre-Natal Vitamins
When women consult with a doctor
when trying to conceive, they are
told to begin taking folic acid, and
perhaps additionally pre-natal vita-
mins.
It is important to remember that
when personally selecting pre-natal
vitamins, women should consult with
their medical team.
Pre-Natal Vitamins
This ensures that the chosen vi-
tamins have the recommended
amount of everything needed
during pregnancy, including folic
acid.
Pre-natal vitamins can vary sig-
nificantly and some may not have
the proper amount of folic acid
needed during pregnancy. (4)

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3. What are the benefits?
It is suggested that folic acid can protect a baby
from neural tube defects by at least 50%. (1) (2)
The Centres for Disease Control and Prevention (CDC) states that
women who take the suggested dose of folic acid daily, beginning one
month prior to conception and during the first trimester, help reduce
the baby’s chance of neural tube defects by 50 to 70 percent. (5)
Mothers who have given birth to a baby with a neural tube defect can
reduce the risk of having another child with a neural tube defect by as
much as 70% by taking folic acid. (2) (8)
A 2015 British Medical Journal study said:
"In the absence of mandatory fortification, the prevalence of NTD has
not decreased in Europe despite longstanding recommendations aimed
at promoting peri-conceptional folic acid supplementation and exis-
tence of voluntary folic acid fortification."

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3. What are the benefits?
Folic Acid Also Helps:
When taken before and during preg-
nancy, folic acid can protect a baby
against: (7)(10)
- Low birth weight
- Cleft lip and palate
- Premature birth
Other Benefits
Folic acid may also aid those who
take it in reducing the risk of:
- Several types of cancers
- Heart disease
- Alzheimer's disease

10. 10
4. What happens when you don't take
enough?
An insufficient amount of folic acid in the body
may cause the baby’s neural tube to close in-
correctly and this could develop health issues
known as neural tube defects or NTDs
These defects include: (11)( 12)
Spina bifida:
This occurs when the spinal cord or the vertebrae do not develop cor-
rectly
Anencephaly:
This occurs when major parts of the brain do not develop correctly.
Babies with anencephaly generally do not live long; while babies with
spina bifida are permanently disabled. These serious health issues may
be preventable with the use of folic acid (12).
Neural tube defects, or NTDs, can begin at an early stage in develop-
ment. In some cases, this is before the woman realises she may be preg-
nant. This affects more than 3,000 pregnancies per year in the United
States. (4)

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5. The Irish context
Ireland & NTDs
The Report of the National Commit-
tee on Folic Acid Food Fortification
showed that (13):
- Ireland has one of the highest inci-
dences of NTD’s in Europe.
- Every year between 49 and 93 Irish
babies are affected each year, most
commonly with spina bifida.
Prevention
Between 70%* of NTDs can be
prevented by taking the recom-
mended amount of folic acid – we
have known this since 1991.
*Other studies refer to 50% or be-
tween 50% and 70%:

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5. The Irish context
50% of pregnancies in Ireland are not planned.
The most important reasons why
some Irish women don’t take folic acid
are:
- 50% of pregnancies are unplanned
- Lack of education regarding the importance of
taking folic acid before conceiving and during
the first trimester
- Financial barriers to buying supplements

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5. The Irish context
One big issue as pointed out in the
The Report of the National Com-
mittee on Folic Acid Food Fortifica-
tion (13) is that 50% of pregnancies
are not planned – therefore unless
women of childbearing age appreci-
ate that without taking supplements
they are unlikely to consumed the
recommended amount, this leaves
a large group of women at risk,
straight away.
In fact this study also
found that more than
one third of Irish
women of
childbearing age
consumed no folic
acid at all (35%).

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6. Who is at higher risk?
Higher risk categories include those who smoke
regularly, drink more than one alcoholic drink
per day......read on to disccover a number of
other groups.
- Women with certain genotypes that are associated with a higher risk
of NTDs
- Women with prior pregnancies resulting in NTDs or a family history
of NTDs
- Ladies with certain malabsorption disorders (such as inflammatory -
bowel disease)
- Those suffering from obesity with a Body Mass Index > 35 kg/m2
- Women diagnosed with diabetes
- Women diagnosed with liver disease
- Women diagnosed with sickle cell disease (12)
- Those dealing with lifestyle and compliance issues – these women are
also at an increased risk of developing NTDs and may benefit from re-
ceiving higher dosages of folic acid: (2)
- Women who use anti epileptic drugs
- Those who take folate antagonists (such sulfonamides, asmethotrex-
ate)
- Women who consume more than one alcoholic drink per day (12)
- Women who smoke regularly

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6. Who is at higher risk?
In most cases, women suffering from
obesity are more likely to have a
baby with a neural tube defect. Al-
though the reason remains vague;
some studies suggest that women
with a higher Body Mass Index (BMI)
usually have lower levels of folate in
their blood.
Significantly overweight women
should consult with a healthcare pro-
fessional prior to conceiving.
This is primarily because the
healthcare professional may pre-
scribe more than 400 mcg of folic
acid daily. (2)(4)
If the mother has had a previous
baby with a neural tube defect, it
is important to alert the health-
care professional before attempt-
ing conception.

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6. Who is at higher risk?
If a woman has given birth to a baby with a
neural tube defect previously, she needs to talk
to her doctor before trying to conceive.
Without the assistance of a professional, women in this particular situ-
ation are at a higher risk of experiencing another pregnancy compli-
cated by an NTD. However, the risk can be reduced significantly by tak-
ing a larger dose of folic acid. (1)
Women that have been diagnosed with diabetes or women taking anti-
seizure medications for epilepsy are at a higher risk of having a baby
with an NTD. Seeking the help of a healthcare professional at least a
month prior to conception can help reduce the risk of having a baby
with NTD. The professional can recommend the proper amount of folic
acid and safely monitor the condition. (2)
Research has shown that the body absorbs the synthetic form of folic
acid easier than the form that is available naturally in foods. (12) Gen-
erally, grain products and enriched cereals are fortified with the syn-
thetic form. However, the majority of women don’t eat these types of
foods enough to depend on them as the main source of folic acid.

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7. Foods that can partner folic acid
supplements
Asparagus
Baked potatoes
Broccoli
Brussels sprouts
Cabbage
Chickpeas
Citrus fruits & juices
Collard
Dried beans
Enriched flour and
pasta
Fortified breakfast
cereals
Kale
Peas
Okra
Spinach
Turnip greens
Yeast Extract

18. 18
7. Foods that can partner folic acid
supplements
Before you check out the selection of recipes
which we have created for you, please note the
following advice:
The ingredients of the following recipes, as well
as the foods mentioned on the previous page
are not a permanent solution for the daily re-
quired intake of folic acid.
These foods are considered a partner to the
supplement. This is mainly because the body
absorbs all of the folic acid in the supplement,
but only absorbs some of the folate in the en-
riched foods.
It is also very important to know that folate can
be destroyed when cooking it. Most folates dis-
solve easily in water. This is why steaming or
microwaving vegetables works better than boil-
ing them. Overcooking these type of foods can
destroy the folates that are contained inside. (4)
(12)

19. A
7. Foods that can partner folic acid
supplements
Although some foods in
Ireland are fortified with
folic acid, not everyone
eats these foods.
There has been an on-
going debate about forti-
fying flour, and therefore
bread, however at the
time of writing this still
hasn’t been implement-
ed.
Additionally it is not
possible to add the
full recommended
amount to bread, as
this would result in an
excess of folic acid for
other members of the
population.

20. 20
Asparagus & Ricotta Tarts
Time & Servings
Prep time: > 15 minutes.
Cook time: 30 minutes
Serves 2
Nutritional Analysis:
Calories 423
Fat 28g
Carbs 29g
Protein 16g
Folate 164µg
Ingredients:
200g ready-rolled puff pastry
150g ricotta cheese
20g grated parmesan cheese
6 sun-dried tomatoes, finely
chopped
10-12 asparagus spears, trimmed

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Asparagus & Ricotta Tarts
These stunning little tarts are perfect for a
romantic night in. They are easy to prepare and
use only a few good-quality ingredients. The
dish contains a good amount of folate, calcium
and vitamin K - all essential for baby’s growth
and for your own health.
1 Pre-heat the oven to 190°C/170°C (fan).
2 Unroll the puff pastry and cut two rectangles, widthways. Score an-
other rectangle inside these - leaving a border of about 1cm. Be sure
not to cut through the pastry.
3 Line a baking tray with parchment (or use the parchment the pastry
was rolled in) and place the pastry rectangles on top. Score a criss-cross
pattern around the borders, if you like.
4 Place the pastry in the oven and cook for 15 minutes. Remove from
the oven, cool slightly, and then gently depress the inside windows
with your fingers.
5 While the pastry is cooking, mix the ricotta with the parmesan and
sun-dried tomatoes.
6 Carefully spread the mixture into the windows of the pastry - it helps
to put little ‘dollops’ of the mixture all over - and then top with the as-
paragus spears.
7 Using a pastry brush, use the oil from your jar of sun-dried tomatoes
to glaze the asparagus spears. Place the tarts back into the oven for a
further 15 minutes. Serve warm or at room temperature, with a green
salad.

22. 22
Halloumi Burgers
Time & Servings
Prep time: 10 minutes.
Cook time: 8-10 minutes
Serves 2
Nutritional Analysis:
Calories 266
Fat 11g
Carbs 34g
Protein 13g
Folate 122 µg
Ingredients:
1 block halloumi
5-6 sprouts, very finely shredded
2 spring onions, very finely
shredded
30g chopped dried cranberries
1 egg
Small handful dried breadcrumbs
1 tsp crushed garlic
2-3 tsp cranberry sauce

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Halloumi Burgers
A nice variation from the simple grilled hal-
loumi, these burgers are a cinch to prepare
and can be done a day in advance if necessary.
Sprouts have been included in the burger mix
for a folate hit, while cranberries, good for the
urinary system, provide a hint of sweetness..
1 Rinse the halloumi well to remove excess salt and pat dry with kitch-
en towel. Finely grate into a mixing bowl.
2 Add the shredded sprouts, spring onions, cranberries, breadcrumbs,
egg and garlic and mix until well combined.
3 With your hands, check the mixture is right by taking a small amount
and scrunching into a ball - it should just about stick together, with a
little moisture oozing out. If it is too crumbly, add a little more egg. Too
wet, add more breadcrumbs. Bear in mind the mixture will firm up in
the fridge.
4 Form into patties and place on a plate, then cover with cling film and
chill for at least half an hour.
5 When ready to cook, heat a little olive oil in a frying pan over a me-
dium heat.
6 Cook the patties for 3-4 minutes each side - be careful when you turn
them - until golden brown and heated through.
7 Serve in buns with mayo on the bottom and a spoonful of cranberry
sauce on the top, and a side salad.
.

24. 24
Lamb & Lentil Shepherd’s Pie
Time & Servings
Prep time: 15 minutes.
Cook time: 1 to 1.5 hours
Serves 4
Nutritional Analysis:
Calories 450
Fat 16g
Carbs 42g
Protein 34g
Folate 240 µg
Ingredients:
400g lean lamb mince
1 onion, chopped
2 carrots, peeled and finely diced
1 tbsp. tomato puree
200ml beef or chicken stock
2 bay leaves
1 sprig thyme
100g peas
150g ready cooked lentils (e.g.
from a pouch)
4-5 large potatoes, peeled

25. A
Lamb & Lentil Shepherd’s Pie
This hearty and warming dish is perfect for cold
nights, and can be made ahead and reheated
as well as frozen for later. The lamb’s liver is op-
tional, but it is worth including as it gives a rich
depth to the dish - as well as being an excellent
source of folic acid.
1. Preheat the oven to 180°C (fan). Put a pan of water on to boil and
place a large, deep frying or sauté pan over a medium heat.
2. In the sauté pan, dry-fry the lamb mince until browned, then add the
onion and carrots. Cook, stirring, for 5-7 minutes until the onion and
carrot are beginning to soften.
3. Add the lambs liver, if using, and cook a further two minutes before
adding the tomato puree. Stir well.
4. Add the stock, thyme and bay leaves and lower the heat. Simmer for
15-20 minutes.
5. Meanwhile, chop the potatoes into even-sized chunks and add to the
pan of boiling water. Cook for 10-15 minutes until very tender, then
drain and mash with a generous knob of butter.
6. Once the potatoes are cooked and mashed, add the lentils and peas
to the lamb mixture and pour or ladle this into an oven-proof casserole
dish.
7. Top with the mashed potato and spread into an even layer. Pop the
casserole into the oven and cook for 20-30 minutes, until turning gold-
en brown on the top. Leave to rest for 5 minutes, then serve with green
vegetables such as broccoli.
.

26. 26
Pasta Primavera
Time & Servings
Prep time: 10 minutes.
Cook time: 15 minutes
Serves 2-3
Nutritional Analysis:
Calories 440
Fat 3g
Carbs 84g
Protein 24g
Folate 211 µg
Ingredients:
200g pasta shapes of your choice
A small onion, chopped
6-8 asparagus tips
75g sugar snap peas, trimmed
120g sprouting broccoli, trimmed
75g frozen or freshly-shelled peas
Splash white wine
2 tbsp. crème fraiche
Mixed soft herbs, such as parsley,
dill, chives.

27. A
Pasta Primavera
A lovely summery dish teeming with fresh
vegetables, this is a cinch to prepare and cook.
The broccoli, peas and asparagus are all good
sources of folic acid and make this a perfect
lunch or supper for vegetarians. Look out, also,
for fortified pastas on the supermarket shelves,
or just use whole-wheat.
1. Bring a saucepan of water to the boil, and heat a sauté pan over a me-
dium heat.
2. Add a splash of olive oil to the sauté pan and gently fry the onions
until softened but not coloured.
3. Cook the pasta according to the pack instructions. When there are
only 3 minutes left of cooking time, throw in the broccoli to the same
pan.
4. At this point, add a splash of white wine to the pan with the onions,
and bubble for two minutes before adding the frozen peas and crème
fraiche. Turn down the heat.
5. For the final minute of pasta cooking time, add the sugar snaps and
asparagus. Blanch for one minute then drain everything through a
sieve, reserving about half a cup of pasta water.
6. Mix the pasta and veggies into the onion, pea and crème fraiche mix
and stir gently to combine. Stir through your chosen herbs, then serve.
.

28. 28
Vegetable Gratin
Time & Servings
Prep time: 10 minutes.
Cook time: 35-40 minutes
Serves 2-4
Nutritional Analysis:
Calories 631
Fat 48g
Carbs 26g
Protein 23g
Folate 281 µg
Ingredients:
One medium head broccoli
10-12 sprouts, blemished leaves
removed and halved if large
300ml double cream
150g finely grated Emmental or
cheddar cheese
10g each parsley and chives
Pinch salt and pepper

29. A
Vegetable Gratin
A very simple dish which is great alone with a
side salad, or as an accompaniment alongside
grilled chicken or fish. This dish is quite high in
fat, so If you are watching the calories feel free
to swap to low-fat cream and cheese.
1. Bring a saucepan of water to the boil, and heat a sauté pan over a me-
dium heat.
2. Add a splash of olive oil to the sauté pan and gently fry the onions
until softened but not coloured.
3. Cook the pasta according to the pack instructions. When there are
only 3 minutes left of cooking time, throw in the broccoli to the same
pan.
4. At this point, add a splash of white wine to the pan with the onions,
and bubble for two minutes before adding the frozen peas and crème
fraiche. Turn down the heat.
5. For the final minute of pasta cooking time, add the sugar snaps and
asparagus. Blanch for one minute then drain everything through a
sieve, reserving about half a cup of pasta water.
6. Mix the pasta and veggies into the onion, pea and crème fraiche mix
and stir gently to combine. Stir through your chosen herbs, then serve.

30. 30
Bibliography
(1) Folic Acid for the Prevention of Neural Tube Defects
http://pediatrics.aappublications.org/content/104/2/325.full
(2) Identifying women who might benefit from higher doses of
folic acid in pregnancy
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3325450/
(3) Folic acid supplementation before and during pregnancy in
the Newborn Epigenetics Study (NEST)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038155/
(4) Folic acid: Why you need it before and during pregnancy
http://www.babycenter.com/0_folic-acid-why-you-need-it-be-
fore-and-during-pregnancy_476.bc?page=1
(5) Folic acid: influence on the outcome of pregnancy
http://ajcn.nutrition.org/content/71/5/1295s.full

31. A
Bibliography
(6) Folic acid supplementation, dietary folate intake during preg-
nancy and risk for spontaneous preterm delivery: a prospective
observational cohort study
http://www.biomedcentral.com/1471-2393/13/160
(7) Effect of folate intake on health outcomes in pregnancy: a
systematic review and meta-analysis on birth weight, placental
weight and length of gestation
http://www.nutritionj.com/content/11/1/75
(8) Folic acid use in pregnant Women presenting to the emergen-
cy department
http://www.intjem.com/content/4/1/38
(9) Patterns and predictors of folic acid supplement use among
pregnant women: the Norwegian Mother and Child Cohort Study
http://ajcn.nutrition.org/content/84/5/1134.full

32. 32
MERRION FETAL
HEALTH
Conveniently located in Dublin 2, Merrion
Fetal Health is a medically led ultrasound
clinic, that offers the reassurance of medi-
cal excellence in obstetric, gynaecological
and fertility ultrasound.
To book an appointment or make an
enquiry:
Call: (01) 663 5060
Website: www.merrionfetalhealth.ie