A 2017 global update on folic acid-preventable spina bifida and anencephaly

Birth Defects Res. 2018 Aug 15;110(14):1139-1147. doi: 10.1002/bdr2.1366. Epub 2018 Aug 2.


Background: Spina bifida and anencephaly are largely preventable birth defects through mandatory folic acid fortification. Our objective was to estimate the proportion of folic acid-preventable spina bifida and anencephaly (FAP SBA) prevented worldwide through mandatory fortification of wheat and/or maize flour with folic acid during the year 2017.

Methods: Using existing data, we identified countries with mandatory fortification policies that added at least 1.0 ppm folic acid to wheat and/or maize flour and had information on percentage of industrially milled flour that is fortified. We assumed mandatory folic acid fortification at 200 μg/day of folic acid fully protects against FAP SBA, reducing the prevalence of spina bifida and anencephaly to 0.5 per 1,000 live births.

Results: Overall, 59 countries met our criteria for implementing mandatory folic acid fortification of wheat and/or maize flour in 2017. These countries prevented about 50,270 out of 280,500 FAP SBA births in 2017. Thus, we have only achieved 18% prevention of FAP SBA worldwide. Several countries in Africa and Asia with a high number of FAP SBA-affected births do not have mandatory fortification.

Conclusion: About 230,000 children unnecessarily developed FAP SBA globally in 2017. There is an urgent need for all countries to implement mandatory folic acid fortification, a proven, safe public health intervention that saves money and prevents infant mortality and disability. Prevention of FAP SBA can play an important role in helping countries to achieve their Sustainable Development Goals for health.

Keywords: anencephaly; epidemiology; flour fortification; folic acid; prevention; spina bifida.

MeSH terms

  • Anencephaly / epidemiology*
  • Anencephaly / prevention & control
  • Female
  • Folic Acid / metabolism
  • Folic Acid / therapeutic use
  • Folic Acid Deficiency / epidemiology
  • Folic Acid Deficiency / metabolism
  • Folic Acid Deficiency / therapy
  • Food, Fortified / supply & distribution*
  • Humans
  • Infant
  • Infant Mortality
  • Pregnancy
  • Prevalence
  • Spinal Dysraphism / epidemiology*
  • Spinal Dysraphism / prevention & control
  • Triticum
  • Zea mays


  • Folic Acid