Meeting of the Parliament

Meeting date: Thursday, October 31, 2013

Official Report 809KB pdf

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Folic Acid Awareness Campaign

The next item of business is a members’ business debate on motion S4M-07713, in the name of Malcolm Chisholm, on the folic acid awareness campaign. The debate will be concluded without any question being put.

I invite members of the public who are leaving the gallery to do so as quickly and quietly as possible.

Motion debated,

That the Parliament congratulates the Scottish Spina Bifida Association on its work in providing advice, advocacy and support for people who were born with spina bifida and/or hydrocephalus and for their families and carers; understands with concern that, in Scotland, 52% of women are not aware of how they could help prevent spina bifida; welcomes the National Folic Acid Awareness campaign, Are You Getting Enough?, which will be launched by the association on World Spina Bifida Day on 25 October 2013; hopes that, in order to help prevent spina bifida and other neural tube defects, the campaign will encourage a greater number of women in Edinburgh Northern and Leith and throughout Scotland to learn about the importance of taking folic acid prior to pregnancy, and supports the association in its aim of ensuring that folic acid awareness should be part of family planning education throughout Scotland.

12:35

I am pleased to speak to my motion. I think that this is the first time that the Parliament has discussed issues that relate to spina bifida, so I will begin by talking about the condition. The term “spina bifida” is Latin for “split spine” and refers to a fault in the development of a baby’s spinal cord. The neural tube, which goes on to become the spine and brain, fails to close properly—that fault may occur as early as 28 days after conception.

Spina bifida is, along with its associated condition, hydrocephalus, the most common and severe birth defect in Europe. Moreover, Scotland has historically had a higher prevalence of neural tube defects than anywhere else in Europe. The conditions profoundly affect the lives of more than 3,500 children, young people and adults in Scotland.

A woman usually does not know that she is carrying a baby that is affected by spina bifida until she has her 20-week scan. She might then have only 48 hours to decide whether to keep or abort her child, which is by then fully formed. That is an extremely traumatic situation for the mother.

Most people who have spina bifida are born paralysed from the waist down, and also suffer severe bladder and bowel problems. Eighty per cent have hydrocephalus, which causes a range of neurological conditions. There is no known cure, and both conditions cause lifelong and complex disabilities. However, a significant number of affected pregnancies could be prevented; I will come back to that key point.

The Scottish Spina Bifida Association is the only charity in Scotland that is dedicated to providing advice, advocacy and support for people who are born with spina bifida and/or hydrocephalus, and for their families. I am delighted that some of its supporters are in the gallery today. I had the privilege of hosting a reception in the Parliament yesterday evening, which a number of MSPs attended. The Minister for Public Health, Michael Matheson, spoke at it, along with a wonderful 10-year-old girl from Glasgow called Ella, and Dr Margo Whiteford, who is a clinical geneticist from Glasgow with spina bifida and who I am pleased to say is also in the gallery.

Dr Whiteford is the SSBA’s chairperson; earlier this year, she became president of the International Federation for Spina Bifida and Hydrocephalus. To reflect that wider focus, the association decided that Scotland should for the first time mark world spina bifida and hydrocephalus day, which was on 25 October. The day serves to remind the public and policy makers of the need to increase awareness of the conditions, in order to help to improve the lives of people who live with them.

The association’s contribution is its major public health campaign, which is entitled, “Are you getting enough?” The campaign was triggered by the shocking statistic that only 48 per cent of women in Scotland are aware that they could help to reduce the risk of their pregnancy being affected by spina bifida by taking a folic acid supplement before conception.

Most women do not start taking folic acid until they have tested positive for pregnancy, when it is often too late to prevent spina bifida. There is strong evidence that taking folic acid—vitamin B9—at least three months before conception can help to reduce the risk of spina bifida and other neural tube defects by 72 per cent. The association’s campaign is about getting that message across to women who are planning a pregnancy or who might become pregnant. It is also about making folic acid awareness part of family planning education throughout Scotland. The campaign builds on the advice that has been issued by NHS Health Scotland that every woman who might become pregnant should take a daily tablet that contains 0.4mg of folic acid before they conceive and during the first 12 weeks of pregnancy. It is easy to buy folic acid tablets and many multivitamin formulas also contain 0.4mg of folic acid. Women who are eligible for the healthy start scheme can also get free vitamins containing folic acid, vitamin C and vitamin D.

Some women are at increased risk of having a baby with a neural tube defect. They include women with diabetes, women who are taking anti-epilepsy medication, women who have coeliac disease and women who have a partner who has a neural tube defect or a family history of such defects. They should ask their general practitioner to prescribe the higher daily dose of 5mg. Moreover, women who are very overweight are at greater risk of having babies with spina bifida, so the advice is that they should seriously consider trying to lose weight before planning a pregnancy.

People can also get folic acid through their diet, in which it is known as folate. Good sources of folate are berries, oranges, peas, lentils, granary and wholemeal breads and fortified breakfast cereals. However, supplementation is still required for maximum benefit.

In relation to fortification, the Food Standards Agency has for some years recommended mandatory fortification of bread or flour with folic acid in order to reduce the risk of neural tube defects. That recommendation has been reinforced by the scientific advisory committee on nutrition. The Scottish Spina Bifida Association strongly supports fortification, because it would help to avert the risks that are associated with unplanned pregnancies. I believe that ministers are considering fortification; I hope that Michael Matheson has something to say about it in his reply to the debate.

I am grateful for the opportunity to use the debate to raise awareness of these little-known conditions. As my motion indicates, I also wish the Scottish Spina Bifida Association every success with its campaign to encourage greater numbers of women, in my constituency and throughout Scotland, to understand the importance of taking folic acid prior to pregnancy, in order to help prevent spina bifida and other neural tube defects.

12:42

I apologise because I have to leave early for another meeting at 1 o’clock.

I congratulate Malcolm Chisholm on securing the debate and I commend all those who have been involved in the folic acid awareness campaign for their efforts. In particular, I pay tribute to the Scottish Spina Bifida Association. I hope that the launch of its campaign last Thursday, on world spina bifida day, was a success and that it will lead to change.

The question for Parliament is this: what should that change look like and how can we help make it happen? We know that the better women who are expecting babies manage their health, the better the outcomes are for everyone. We can prevent illness and long-term conditions, ensure a better pregnancy for mother and child and give every baby a better start in life. As the Scottish Spina Bifida Association makes clear, we can reduce the number of pregnancies that are affected by spina bifida and other neural tube defects.

Let us be clear: support for children with spina bifida is better than ever. Our understanding of spina bifida and neural tube defects has improved, medical technology has advanced and paediatric neuroscience has evolved. However, there is a strong case for prevention; taking folic acid in the right quantities is the key to that.

There is no shortage of information about the importance of folic acid and foods that are sources of vitamin B, but that information has to get to women who are expecting children and couples who are thinking about starting families. There are examples in the health service of best practice—of how that information can be presented in an accessible and instructive way. We need to learn from that best practice, and we can make a real difference by raising public awareness more generally and, I hope, getting the message to people pre-pregnancy. This is not about lecturing the public; it is simply about explaining how a readily available substance in the right amounts benefits them and their children.

My appeal today is that the Government and the chief medical officer work constructively with campaigners. We have seen progress on fortified foods; now, we have to see progress on public awareness. The will is there, the science is sound and the benefits cannot be ignored.

12:44

I offer hearty congratulations to Malcolm Chisholm for giving us the opportunity to discuss this important topic. He suggested—I cannot rebut this—that this is the first time that the subject of spina bifida has been debated in the Scottish Parliament.

Malcolm Chisholm’s motion focuses—as did his speech—on the need to ensure that women are better informed. I suggest that there may be a marginal benefit in ensuring also that men are better informed, despite their comparatively modest role in bringing children into the world. Partnerships are the best environment in which children come into the world, and I hope that the presence of men in the public gallery and in the debate shows that we, too, are interested.

In bringing the debate to the chamber, Malcolm Chisholm has forced me to consider the matter in a material way for the first time, and to look at the Scottish Spina Bifida Association’s website. I found the website to be engaging, interesting and informative, because of its focus on the “Are you getting enough?” campaign to raise women’s awareness, which is absolutely excellent.

The website mentions the role that diet can play in increasing the amount of folic acid that we all—women in particular—take. Looking at the list of foods that help us in that way, I found nothing but things that I am rather keen to eat. The list includes broccoli, brussels sprouts, liver—not everyone’s favourite, but I love it—spinach, asparagus, peas, chickpeas, brown rice and fortified breakfast cereals. Indeed, I went away and got a wee recipe for chickpea curry from Nigella Lawson’s website; I am now feeling hungry just thinking about it. Furthermore, a quick calculation has shown me that it costs about £1.20 per serving to make a chickpea curry, so it is not only good for you but economically effective too, which is important in these straitened times.

Even more important is that the list mentions fortified breakfast cereals. One cereal that delivers a wide range of benefits is, of course, porridge. If porridge is made from oats that are not overprocessed, it contains a decent amount of folic acid. For pregnant women, porridge is an excellent way to start the day, because it apparently reduces the risk of constipation, which is one of the side-effects of pregnancy. It will always top up the body’s folic acid, and it is a natural weight-loss agent because it fills you up and makes you less hungry. I commend porridge as one of the ways forward.

Food helps, but it is not in and of itself the complete answer; we also need supplements to ensure that we have appropriate folic acid input. I have seen a complex range of figures for people with different pre-existing conditions, and there is some indication that overconsumption of folic acid could cause problems in relation to the suppression of vitamin B12 deficiency.

Advice from professionals is important, and the motion focuses on how advice can be given as part of contraceptive and birth control advice. That is an excellent basis on which to deal with the problem.

12:48

I also offer my thanks to Malcolm Chisholm for bringing the debate to the chamber and for highlighting the welcome addition of the national folic acid awareness campaign “Are you getting enough?” as one of the measures that can contribute to prevention of spina bifida.

I also thank Malcolm Chisholm for hosting yesterday evening’s excellent reception, which gave us so much interesting information about the Scottish Spina Bifida Association and its campaign to educate women on the importance of taking folic acid before pregnancy and during the early months of pregnancy in reducing the incidence of neural tube defects such as spina bifida and hydrocephalus. I learned that milling flour removes folic acid, and that to replace it by fortifying flour in bread might be a very sensible idea.

I was also delighted to meet my North East Scotland constituents Wendy Hulse and her son Jay from Aberdeen, who are enthusiastic supporters of the SSBA campaign. I have apologies to offer them from their constituency member Mark McDonald, who is unable to attend this debate because of other parliamentary commitments.

Spina bifida is one of the most common birth defects, with a worldwide incidence of about one in every 1,000 births. In Scotland alone, more than 3,500 people, from children to adults, live with the condition every day. In the United Kingdom, it is a startling statistic that every day, two babies are conceived with a neural tube defect such as spina bifida, which demonstrates just how prevalent the conditions are.

Although there is neither a single cause nor any known way to prevent it entirely, there is—as we have heard—evidence to suggest that dietary supplements that contain folic acid can help to reduce the incidence of spina bifida.

The message that needs to be put across is that women in Scotland who are sexually active and who are at an age when pregnancy is possible need to be aware that they can go some way towards reducing the possibility of having a child with a neural tube defect if they take folic acid. Common sense dictates that every woman would want her child to be safe and healthy, and anything that can contribute to making that a reality should be part of any form of family planning. If using folic acid for three months prior to conception can reduce the occurrence of neural tube defects by a staggering 72 per cent, that fact needs to be communicated effectively and forcefully.

As Malcolm Chisholm says in his motion, 52 per cent of women in Scotland are unaware that folic acid can be a part of preventative measures, so that lack of knowledge has to be addressed. That is why I welcome the SSBA’s latest campaign, “Are you getting enough?” The campaign is accompanied by a glossy leaflet showing a bare-chested Scotsman in a kilt, which certainly helps to grab one’s attention. If placing such a leaflet in surgeries, health centres and maternity clinics succeeds in getting women to pick it up and read it, the first step in the campaign has been achieved.

The leaflet contains easy-to-read material in which the facts are put across in a lively yet informative manner, giving clear guidance on the effectiveness of folic acid. Further information is given on the recommended dosage of folic acid tablets, which should be higher for women who have diabetes, who have coeliac disease, or who are taking anti-epilepsy medications—as we heard from Malcolm Chisholm. I therefore commend the SSBA for what I hope will prove to be a very effective campaign.

We could also learn something from the United States, where folate fortification of grain-based products including breakfast cereals has been mandatory since 1998. I would welcome hearing the minister’s views on such action when he sums up.

The motion also mentions the great work that is undertaken by the families and carers of individuals who have spina bifida, and in that context I pay tribute to the family group in my home city of Aberdeen, which meets monthly and which has been offering support since the 1960s, and to institutions such as the Persley Castle nursing home in Bucksburn, which specialises in the care of people with spina bifida.

Finally, I am sure that colleagues will join me in congratulating the organisers of world spina bifida day, which is now in its second year, and in wishing them well for the future as they work to raise awareness of the condition and of how its incidence can be reduced. I congratulate Malcolm Chisholm on bringing the issue to our attention.

12:53

In welcoming the debate, I join my colleagues in congratulating Malcolm Chisholm on securing it. Spina bifida is a very important issue, so I am rather surprised that this is the first time that we have debated it in the chamber. I certainly do not think that it should be the last time. I was also surprised that Nigella Lawson merited a mention in the debate but rather less surprised that it was Stewart Stevenson who managed to mention her.

I apologise to Malcolm Chisholm and to the Scottish Spina Bifida Association for being unable to attend last night’s reception. The SSBA is an organisation that I know very well because it is based in my constituency, in Cumbernauld. I have been very happy to visit it many times and, indeed, I have visited it previously with the Minister for Public Health.

Under the direction of its chief executive, Andy Wynd, the SSBA is playing an outstanding role in supporting families where someone has spina bifida. If members have been unable to visit the SSBA headquarters, it is well worth a visit—it is an excellent facility. When families learn that they have a child who has spina bifida it must be a very frightening time for them and the facility is a very welcoming place. The association is also doing great work to raise awareness of the condition, through the folic acid awareness campaign that is the subject of this debate.

The most recent figures in Scotland confirm that around one in 1,000 pregnancies is affected by spina bifida. Some people might consider that rate to be fairly low, but last year there were just under 60,000 births in Scotland, which suggests that around 60 children were born with spina bifida. We must remember that the rate is higher in Scotland than it is elsewhere, as Malcolm Chisholm said, and that the condition can be very severe and have a huge impact on the life of the person and their family—I am sad to say that some people who suffer from the condition die in infancy. We must remember that there are individuals and families behind the figures, who are struggling with a serious condition.

That is why the folic acid campaign is so important. We do not know what causes the condition, and research continues, but we know that folic acid supplements can reduce the risk of spina bifida affecting an unborn baby. As Malcolm Chisholm said, where there is no family history of spina bifida it is recommended that women take a dose of 400 micrograms a day; where there is a history of spina bifida a dose of 5mg is required.

That approach helps to reduce the occurrence of neural tube defects by some 72 per cent but, despite the guidance that is out there, only about half the women who become pregnant take folic acid before conceiving. It is important to emphasise that those women are planning to become pregnant, which suggests that there is some way to go to raise awareness of the issue more generally.

I welcome the Scottish Spina Bifida Association’s efforts. It would be helpful to know how the Scottish Government can support the campaign and what it is doing to improve uptake of folic acid. I look forward to hearing what the Minister for Public Health has to say in that regard, and I again congratulate Malcolm Chisholm on securing this important debate.

12:57

I congratulate Malcolm Chisholm, as other members have done, on bringing this debate to the Parliament, which is about furthering awareness of an issue of which many people in Scotland are perhaps not as aware as they should be.

People might have heard of spina bifida, but many will not understand its causes and how it might be prevented. The Scottish Government began its report “Improving Maternal and Infant Nutrition: A Framework for Action” by saying:

“The Scottish Government wants to ensure that all children have the best possible start to life”.

I think that all members can agree on that. In the report, the Government recognised that the diet and nutritional health of the mother before conception and during pregnancy are key factors in the health of the foetus.

An individual’s socioeconomic status can be a determining factor in many issues to do with health. That is the case for pregnant mothers. The growing up in Scotland study survey found that 81 per cent of women who had lower-level standard grades had taken folic acid when they were pregnant, compared with 96 per cent of the women who were educated to degree level. Some 81 per cent of women in the lowest income group had taken folic acid, compared with 97 per cent in the highest income group. The figures show that some children are already at a disadvantage when they are born into this world.

In the same study it was found that only 48 per cent of women took folic acid prior to their pregnancy but 90 per cent took folic acid during their pregnancy. However, we should note that not all pregnancies are planned and that that could affect those figures.

The Scottish Spina Bifida Association’s “Are you getting enough?” campaign highlights an issue that has been prevalent in Scotland for some time now. According to Eurocat—European surveillance of congenital anomalies—Scotland had in 2010 a higher prevalence of neural tube defects compared with other European nations. Although the national health service has produced guidelines to inform women about neural tube defects, over 50 per cent of sexually active women are not taking folic acid on a regular basis. However, it is thought that compliance with the NHS guidelines could see cases of neural tube defects reduced by up to 72 per cent. If we are to tackle this problem, we need to ensure that we give expectant mothers fair and equal treatment to ensure that each one’s child is born with the best possible chance in life.

Although the taking of folic acid before and during pregnancy does not totally remove the risk of a child contracting spina bifida, it reduces the risk significantly. Dr Margo Whiteford, consultant and chair of the Scottish Spina Bifida Association, states:

“It just reduces the risk, probably between two-thirds and three-quarters.”

I reiterate how vitally important the Scottish Spina Bifida Association’s “Are you getting enough?” national folic acid awareness campaign is in drawing attention to the necessity for every woman who is planning to become pregnant or who is sexually active and might become pregnant to take folic acid as directed by their GP. I am pleased to note that Michael Matheson, the Scottish Government’s Minister for Public Health, has backed the campaign, which endorses the NHS guidelines.

13:02

I join others in congratulating Malcolm Chisholm on securing this most important debate and in welcoming the Scottish Spina Bifida Association’s campaign.

I am delighted to have the opportunity to take part in this debate on the importance of folic acid, a subject about which I have been concerned for a number of years. Folic acid, or vitamin B9, was identified in the late 1930s as part of the great increase in understanding of the vital nutrients naturally present in food that happened in the years between the wars. Folic acid was isolated in spinach leaves in the early 1940s, but it was not until 1960 that deficiency of folic acid was linked to neural tube defects in babies.

We all recognise that spina bifida and hydrocephalus are devastating conditions that cause paralysis and bowel problems, and often cause neurological problems. Nevertheless, the good news is that 72 per cent—nearly three quarters—of cases could be prevented by the simple act of adding folic acid to flour. The problem is that neural tube defects happen early in a pregnancy—often as early as the 28th day after conception—so unless folic acid supplementation is started before conception it is all too easy to miss that very small window in which a baby can be protected. That is why countries as diverse as Canada, the United States, South Africa, Chile and Australia have opted for mandatory supplementation of flour with folic acid. That ensures that all women in those countries of child-bearing age are getting the folic acid that they need in their diets.

Of course, as always with supplementation, there are risks that must be weighed in the balance. For example, in supplementing flour with folic acid there is a risk for the group of elderly people who have pernicious anaemia, whose symptoms could be masked by that supplementation. Any move to supplement flour with folic acid would therefore need to be accompanied by measures for health professionals to tackle pernicious anaemia, which is a vitamin B12 deficiency. However, that is entirely manageable, and with proper guidance to GPs it could be dealt with relatively straightforwardly.

It is important to point out that fortification of food is the norm and that it has been so for many years. Many foods in Scotland are already fortified. For example, by law in the UK, iron, thiamine and niacin must be added to flour as they are removed with bran during the milling of wheat. Margarine is also fortified by law with vitamins A and D.

Food supplementation has been with us for decades and dates back to the days of rationing, when the UK Government, armed with the knowledge that had been gained by scientists in the 20s and 30s, understood the consequences of rationing. It did that because of the work of, among others, our own John Boyd Orr in Glasgow—one of the foremost nutritional scientists of the 20th century and a man known as the father of modern nutrition. He knew that many people in Scotland had too little money to feed themselves and their families properly.

It is well known among health professionals that advice and knowledge are eagerly seized upon and utilised by the most educated and well-off sections of the population. Anne McTaggart mentioned that in her speech. That is not a bad thing, because if even one child is protected from a neural tube defect, we should be delighted. However, the danger—it is one that we, as legislators, have to consider—is that we leave the poorest and most vulnerable women and children in our society behind and unprotected.

If we fail to fortify flour with folic acid, we run the very real risk that people who do not have the money for folic acid supplements—we should not forget that the advice is to take folic acid supplements for at least three months before the woman gets pregnant, which is often an open-ended commitment—will not get the protection that better-off parts of the population receive. Many of those women are too pushed to think about supplementation, but they and their children need protection too. In addition, we must not ignore the fact that many pregnancies are not planned and therefore women will not have been taking folic acid as recommended. Supplementation would protect them as well.

The Food Standards Agency in Scotland recommends mandatory fortification of bread or flour with folic acid, and it has done so since 2009. I am pleased to say that that is also SNP policy. I do not need to remind the minister of that. In a motion that I put before national conference in October 2006, conference agreed that the

“SNP supports the addition of folic acid to flour and/or other grain products sold in Scotland to dramatically reduce the number of children born in Scotland who suffer from neural tube defects.”

That is the great point—neural tube defects would drop like a stone if folic acid was added to flour and products made from flour.

You might wish to draw to a close, please.

Thank you, Presiding Officer.

I know that the Scottish Government is considering, along with the other Administrations, the addition of folic acid to flour, and I would be delighted if the Minister for Public Health could indicate when he expects a decision to be taken.

I feel very strongly that the addition of folic acid to flour and flour-based products in Scotland would be an extremely important step in protecting the health of every baby in Scotland, and I am sure that we all agree that it is something that we should support.

13:07

Like others, I congratulate Malcolm Chisholm on securing time for this debate. I thank all the members who have spoken for their speeches, which I listened to closely.

I am sure that all members recognise that having a child or family member with a disability can be hugely challenging for parents and carers and the family as a whole, and the work that the Scottish Spina Bifida Association does is essential in supporting families with children who have spina bifida. The presentation last night by the parents of Ella, a 10-year-old child who came along, clearly demonstrated some of the challenges that they have faced and also some of the ways in which they have been assisted by the Scottish Spina Bifida Association. However, no one could be left in any doubt that, when it comes to having a discussion on spina bifida or any other issue, Ella would have the last word. She is clearly a very inspiring young 10-year-old.

I am sure that members will note with concern that some 52 per cent of women in Scotland are not aware of how they could prevent spina bifida and other neural tube defects. The Scottish Spina Bifida Association’s national folic acid awareness campaign—“Are you getting enough?”—is an important part of its work. It aims to encourage a greater number of women across Scotland to learn about the importance of taking folic acid prior to and during the early stages of their pregnancy.

It is known that not having enough folic acid during pregnancy is the most significant risk factor for spina bifida. As a Government, we are clearly committed to improving the health and wellbeing of the Scottish population as a whole and ensuring that children get the best possible start in life. That is why we published “Improving Maternal and Infant Nutrition: A Framework for Action” back in January 2011. That framework for action is to be implemented by health boards, local authorities and others, with the aim of improving the nutrition of pregnant women, babies and young children. It is the first framework of its type that looks at the nutrition of mothers before and during pregnancy.

During pregnancy, there is an increased demand for several key nutrients such as vitamin D and folate. The increased demand for vitamin D and folate cannot be met from food sources alone, which is why it is recommended that all pregnant women take a daily supplement of each in addition to increasing their dietary intake. As Malcolm Chisholm said in his speech, the Scientific Advisory Committee on Nutrition recommends that, before conception and until the 12th week of pregnancy, women should take a folic acid supplement of 400 micrograms per day to reduce the risk of having an infant with a neural tube defect. In addition, women are advised to eat foods that are rich in folate and folic acid to increase their nutrient intake to 300 micrograms per day for the duration of their pregnancy. Some of the recipe ideas that Stewart Stevenson offered are a good example of how women can do that.

NHS Health Scotland has launched an updated leaflet with information on folic acid before and during pregnancy. The leaflet, which is free and widely available, provides basic information on folate from foods, folic acid supplements and fortified food products, and recommendations on intake for women before pregnancy and up to their 12th week of pregnancy. Its recommendations are in line with the SACN recommendations, and advice is also available to professionals on the advice that they should provide on folic acid to ensure that all health professionals see themselves as having a role in promoting folic acid supplements.

Through implementation plans provided by our NHS boards, we are aware of the specific work that the boards are undertaking to raise awareness of folic acid supplementation before and during pregnancy, which is mainly targeted at particular groups including women who have experienced pregnancy loss or who are at high risk and attend pre-conception clinics.

In Scotland, women and babies who are at the greatest risk of poor health outcomes are the least likely to access and/or benefit from the antenatal health care that they need. That can significantly hamper the contribution that maternity care services can make to improving health and reducing health inequalities. We know that just having access to antenatal care is insufficient; it needs to be accompanied by a focus on the continuous and effective assessment of health and social need to identify any prevention and early intervention actions that are needed before babies are born and in the early days of their lives. We need to know what to do more effectively, and maternity care staff need to work in partnership with each other and with women and their families to address the issues effectively.

That is why NHS boards have an antenatal access HEAT—health improvement, efficiency, access to services and treatment—target, which means that at least 80 per cent of pregnant women in each of the lower quintiles will be booked into antenatal care by the 12th week of gestation by March 2015. That will ensure improvements in this area.

A number of members referred to the fortification of flour and products made from flour, and the chief medical officer, the Food Standards Agency in Scotland, I and the Scottish Government as a whole are clear that the fortification of bread or flour with folic acid is an important way of increasing the folic acid intake of women who might become pregnant. I am also clear that it would be an effective way of reaching sections of the population with the lowest folate intakes.

We are working with our colleagues in other parts of the United Kingdom to develop a UK-wide approach to mandatory fortification and we are actively considering the mandatory fortification of flour with folic acid with our partners in other parts of the UK. I have requested further advice from the Food Standards Agency in Scotland on this matter and I expect it to provide updated information early in the new year.

We as a Government very much welcome the Scottish Spina Bifida Association’s national folic acid awareness campaign, which is very much in line with the advice that we provide. I wish it well with the campaign and it can be assured that we as a Government will continue to look at what measures can be taken to reduce the incidence of neural tube defects in Scotland, including the possibility of taking forward mandatory fortification of flour and bread with folic acid.

13:15 Meeting suspended.

14:30 On resuming—