Prevention of Neural Tube Defects in Europe: A Public Health Failure

Abstract

Objective: Thirty years ago it was demonstrated that folic acid taken before pregnancy and in early pregnancy reduced the risk of a neural tube defect (NTD). Despite Public Health Initiatives across Europe recommending that women take 0.4 mg folic acid before becoming pregnant and during the first trimester, the prevalence of NTD pregnancies has not materially decreased in the EU since 1998, in contrast to the dramatic fall observed in the USA. This study aimed to estimate the number of NTD pregnancies that would have been prevented if flour had been fortified with folic acid in Europe from 1998 as it had been in the USA.Design and Setting: The number of NTD pregnancies from 1998 to 2017 that would have been prevented if folic acid fortification had been implemented in the 28 countries who were members of the European Union in 2019 was predicted was predicted using data on NTD prevalence from 35 EUROCAT congenital anomaly registries and literature searches for population serum folate levels and folic acid supplementation.Results: From 1998 to 2017 an estimated 95,213 NTD pregnancies occurred amongst 104 million births in the 28 countries in the EU, a prevalence of 0.92 per 1,000 births. The median serum folate level in Europe over this time period was estimated to be 14.1 μg/L. There is a lack of information about women taking folic acid supplements before becoming pregnant and during the first trimester of pregnancy, with one meta-analysis indicating that around 25% of women did so. An estimated 14,600 NTD pregnancies may have been prevented if the European countries had implemented fortification at the level adopted by the USA in 1998 and 25% of women took folic acid supplements. An estimated 19,500 NTD pregnancies would have been prevented if no women took folic acid supplements.Conclusions: This study suggests that failure to implement mandatory folic acid fortification in the 28 European countries has caused, and continues to cause, neural tube defects to occur in almost 1,000 pregnancies every year.

Preventing birth defects, saving lives, and promoting health equity: an urgent call to action for universal mandatory food fortification with folic acid

“…Except for Moldova and Kosovo, no other European country implements mandatory folic acid fortification, resulting in more than 1000 pregnancies affected by spina bifida and anencephaly that are preventable every year in Europe. 18 Many countries in Africa and Asia also do not implement folic acid fortification.…”

Dietary Intake of Folate and Assessment of the Folate Deficiency Prevalence in Slovenia Using Serum Biomarkers

“…In many countries, less than 50% of women follow these recommendations [97,98]. Furthermore, pregnancies are not always planned, and some researchers note that fortification of foods with folic acid could substantially lower risks for neural tube defects in Europe [99]. In our study, adult women were the population with the lowest prevalence of folate deficiency, but we should note that the prevalence of vitamin supplements use was also the highest in this group.…”

Spina Bifida: A Review of the Genetics, Pathophysiology and Emerging Cellular Therapies

“…In 1996, the Food and Drug Administration (FDA) authorized folate fortification and, by 1998, mandated it [ 112 ]. As of 2021, over 78 countries have mandated folic acid fortification in their flour [ 113 ]. Despite the mounting evidence of a decreased incidence of NTDs with folate supplementation, there are still many countries that forgo fortification and continue to have a significant number of births complicated by NTDs [ 113 ].…”

“…As of 2021, over 78 countries have mandated folic acid fortification in their flour [ 113 ]. Despite the mounting evidence of a decreased incidence of NTDs with folate supplementation, there are still many countries that forgo fortification and continue to have a significant number of births complicated by NTDs [ 113 ]. While it has been demonstrated that folate deficiency is a cause of NTDs, there exist mouse models, as well as human populations, that develop NTDs despite folate supplementation, again underscoring the complex genetic and environmental relationship involved in this process [ 114 ].…”