Updated Estimates of Neural Tube Defects Prevented by Mandatory Folic Acid Fortification


Jennifer Williams, et al. 

Morbidity and Mortality Weekly Report. 2015;64(1):1-5. 

In 1992, the U.S. Public Health Service recommended that all women capable of becoming pregnant consume 400 μg of folic acid daily to prevent neural tube defects (NTDs). NTDs are major birth defects of the brain and spine that occur early in pregnancy as a result of improper closure of the embryonic neural tube, which can lead to death or varying degrees of disability. The two most common NTDs are anencephaly and spina bifida. Beginning in 1998, the United States mandated fortification of enriched cereal grain products with 140 μg of folic acid per 100 g. Immediately after mandatory fortification, the birth prevalence of NTD cases declined. Fortification was estimated to avert approximately 1,000 NTD-affected pregnancies annually. 

The birth prevalences of spina bifida, anencephaly, and both NTDs combined were estimated as the total number of cases divided by the total number of live births during the pre-fortification (1995–1996) and post-fortification periods (1999–2011). These prevalence estimates were multiplied by the average number of live births in the United States for the selected periods to estimate the annual number of NTD cases nationwide. Prevalence estimates were also calculated by type of surveillance program (i.e., programs with prenatal ascertainment and programs without prenatal ascertainment) and maternal race/ethnicity (i.e., non-Hispanic white, non-Hispanic black, and Hispanic). The estimated annual number of NTDs prevented was calculated as the difference between the estimated annual number during the pre-fortification period and the estimated annual number during the post-fortification period using prevalence estimates from programs with prenatal ascertainment.

A decline in NTDs was observed for all three of the racial/ethnic groups examined between the pre-fortification and post-fortification periods (Figure). The post-fortification prevalence has remained relatively stable. During the observed periods, Hispanics consistently had a higher prevalence of NTDs compared with the other racial/ethnic groups, whereas non-Hispanic blacks generally had the lowest prevalence.