30 Years Later, Much Work Remains with Mandatory Folic Acid Fortification to Prevent Spina Bifida Globally

December 20, 2022

A recent research article, led by investigators engaged with the Emory Center for Spina Bifida Prevention and published in Birth Defects Research, provides a global update on folic acid-preventable spina bifida and anencephaly 30 years after the publication of the British Medical Research Council’s groundbreaking study on the effectiveness of folic acid in neural tube defect prevention. Today, folic acid fortification remains a highly effective way to prevent neural tube defects like spina bifida and anencephaly, and, in 2020 alone, 61,680 cases were prevented worldwide thanks to mandatory folic acid fortification of cereal grains (i.e. wheat flour, maize flour, and rice).

Despite the success this number represents, it constitutes just 22 percent of possible folic acid preventable spina bifida and anencephaly cases globally. With 30 years of evidence stressing the life-saving necessity of folic acid, major opportunities for improvement remain, particularly for the more than 100 countries (many with high burdens of preventable folic acid preventable spina bifida and anencephaly) that have still not implemented mandatory folic acid fortification, while about 60 other countries benefit from the intervention. This is an example of global health inequity.

“A global coordinated effort for mandatory folic acid fortification of staples is needed urgently, under the leadership of reputed action-oriented global health agencies, and largely mobilized by champions within the governments, civil-society organizations, parents, physicians, and per- sons with spina bifida,” says Vijaya Kancherla, PhD, deputy director of the Emory Center for Spina Bifida Prevention. “Such efforts will contribute toward the primary prevention of spina bifida and anencephaly, averting stillbirths, and under-five deaths due to these birth defects.”

Spina bifida and anencephaly remain severe birth defects for infants around the world that can result in stillbirths, early childhood deaths, and serious lifelong medical issues among those who survive with spina bifida - these can be both emotionally and economically devastating for impacted families. For many in low- and middle-income countries, there are no surgical services to meet the need for early spinal surgeries, or to address infection and complications. A large majority of these cases are caused by a lack of adequate folic acid in the mother’s diet prior to conception and during the first 28 days of pregnancy. This is the time when most women are unaware of their pregnancies and are not actively taking prenatal folic acid supplement pills. Mandatory folic acid fortification is a cost-effective, equitable intervention that ensures all members of the public (including those who may be unknowingly pregnant) are getting needed folic acid. Political will in countries is key for sustainable prevention of spina bifida and anencephaly.