Renewed calls for global folic acid fortification to prevent spina bifida

Nutrition experts and doctors are calling on the World Health Assembly to pass a resolution for universal mandatory folic acid fortification. Folic acid fortification has been proven since 1991 to reduce neural tube defects, such as spina bifida and anencephaly in babies.

Mandatory food fortification with folic acid is a safe, cost-effective, and sustainable intervention to prevent some types of birth defects and abnormalities which occur during early stages of pregnancy.

These conditions are painful, life-limiting and in serious cases fatal to babies, but are often preventable when the mother has the correct nutrition.

The WHA reports that world-wide at least 300,000 pregnancies are estimated to be affected with spina bifida and anencephaly annually, and 75% of them result in elective terminations, stillbirths, or under-five deaths.

Recently the World Health Assembly marked the 30th anniversary of the landmark publication by the British Medical Research Council that maternal intake of folic acid (vitamin B9) starting before pregnancy prevents most cases of infant spina bifida and anencephaly.

Since the publication of the 1991 UK research by Professor Sir Nicholas Wald and colleagues, more than 80 countries have introduced food legislation making folic acid fortification mandatory, from Antigua to Zimbabwe. It has been in place in the USA since 1998, and most recently in July of this year, New Zealand.

Research by The Lancet showed that  except for Moldova and Kosovo, no other European country implements mandatory folic acid fortification, which they estimate results in more than 1000 pregnancies of preventable neural tube defects every year in Europe. 

However, the United Kingdom doesn’t have mandatory folic acid fornication, but does have mandatory vitamin fornication of flour (calcium, iron, thiamin and niacin) . Instead the UK recommends women who intend on getting pregnant and those in the early stages of pregnancy to take folic acid supplements – however this is unrealistic for most mothers.

Experts state that in developing countries and low-income countries, particularly in Africa where food systems are more local and subsistence farming is the main provider of food to many families, it will be hard to implement and manage fortification programmes. 

But, there is hope, as experts say that fortification can occur through multiple staple foods e.g., wheat flour, maize flour, and rice, and even suggestions about double fortification of salt with iodine and folic acid, as a method when countries lack large-scale milling infrastructure for grain fortification. 

On CABI GH there are over 31,000 records about "fortification" or "folic acid" or "vitamin b9",  with over 1900 records relating to the search ("fortification" or "folic acid" or "vitamin b9") AND ("neural tube defects" or "spina bifida" or "birth defects")

Full list of countries which have folic acid fortification can be found here:


Kancherla, V., Botto, L., Rowe, L., Shlobin, N., Caceres, A., Arynchyna-Smith, A., Zimmerman, K., Blount, J., Kibruyisfaw, Z., Ghotme, K., Karmarkar, S., Fieggen, G., Roozen, S., Oakley, G., Rosseau, G. and Berry, R., 2022. Preventing birth defects, saving lives, and promoting health equity: an urgent call to action for universal mandatory food fortification with folic acid. The Lancet Global Health, 10(7), pp.e1053-e1057.

Wald, Nicholas & Morris, Joan & Blakemore, Colin. (2018). Public health failure in the prevention of neural tube defects: Time to abandon the tolerable upper intake level of folate. Public Health Reviews. 39. 10.1186/s40985-018-0079-6.