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Fortification with folic acid could help prevent severe birth defects in at least 1000 pregnancies per year

In the past 20 years, one in 1 000 pregnancies in the EU was affected by neural tube defects (NTDs), a group of severe congenital anomalies of the central nervous system
In the past 20 years, one in 1 000 pregnancies in the EU was affected by neural tube defects (NTDs), a group of severe congenital anomalies of the central nervous system
Jul 06 2021

Folic acid fortification of grain products could help prevent severe congenital anomalies in at least 1000 pregnancies every year in the EU, suggests a new collaborative study performed by the JRC and EUROCAT.

In the past 20 years, almost one in 1 000 pregnancies in the EU was affected by neural tube defects (NTDs), a group of severe congenital anomalies of the central nervous system, including spina bifida and anencephaly.

However, effective primary prevention is available. Already thirty years ago, it was shown that increasing the intake of a B vitamin called folate (folic acid), before and in early pregnancy, reduces the risk of NTDs.

How can women increase their intake of folic acid?

Changes in the diet alone are not likely to result in a high enough daily intake of folic acid so women should take supplements to reach the optimal intake.

But folic acid can be also added to widely consumed grain products (such as bread, pasta, rice, and/or cereal), to reach practically all women, and often at an earlier stage than with supplements. This is called fortification of food with folic acid.

Increasing the intake of folate early enough

While increasing the intake of folic acid is of utmost importance for preventing the risk of NTDs, so is the timing.

The higher intake of folic acid ideally needs to occur already before a woman becomes pregnant and into 12 weeks of pregnancy. If this is delayed, crucial time may be lost in those critical first weeks, often before a woman knows she is pregnant.

Folic acid fortification worldwide

Almost 80 countries have introduced mandatory fortification of flour with folic acid, starting with the United States of America in 1998.

In the EU, the decisions on mandatory folic acid fortification are the responsibility of Member States and so far none of the countries introduced this population-wide public health measure, which would benefit a only a small group of the population.

Instead, women are currently advised to take folic acid tablets or capsules before pregnancy and in the first trimester to reduce their risk of an NTD pregnancy.

The prevalence of NTDs remains stable in the EU

European countries introduced national recommendations advising women to take periconceptional folic acid supplementation before and during pregnancy to prevent NTDs. Albeit folic acid supplementation recommendations, population coverage and timing may be hampering progress on this regard. Indeed, the prevalence of NTDs in the EU has not decreased since 1998, as EUROCAT data collected at the JRC show.

In contrast, a fall of NTDs was observed in other countries where mandatory flour fortification with folic acid is implemented.

The new study estimated that between 14 600 and 19 500 NTD pregnancies associated with neural tube defects could have been averted between 1998 and 2017 if the European countries had implemented fortification with folic acid at the level and extent adopted by the USA in 1998. These results provide additional evidence to the ongoing valid debate on folic acid fortification in Europe.

This study used data on NTD prevalence from 35 EUROCAT congenital anomaly registries from 1998 to 2017, and literature searches for population serum folate levels and for folic acid supplementation.


To support the implementation of the European Commission's strategy on rare diseases, the JRC in collaboration with DG SANTE developed the European Platform on Rare Disease Registration. Within the EU RD Platform, the JRC operates the Central Registry of EUROCAT, the European network of registries for the surveillance of congenital anomalies. EUROCAT collects data since 1979 and covers about 25% of the European birth population.

Using high quality data collected annually from almost 40 registries, EUROCAT provides essential epidemiological information on congenital anomalies in Europe. The data are also used to detect new teratogenic exposures, to assess the impact of developments in prenatal screening and to evaluate the effectiveness of primary prevention.