Folic Acid

The UK has one of the highest rates of neural tube defects in Europe, with around 1000 pregnancies affected each year. 

It is recommended that women take folic acid supplements prior to conceiving in order to prevent neural tube defects. As 46% of pregnancies in the UK are unplanned, and many women are unaware of the need to take folic acid, most pregnant women even with the best of intentions will start taking folic acid too late in pregnancy to protect their baby from avoidable harm. Fortifying flour with folic acid would mean that it would enter into widely consumed foods, so women will already be consuming the vitamin prior to becoming pregnant. 

 The latest Public Health England figures show that the rate of neural tube defects was 13.7 per 10,000 live births in 2017 – or roughly 930 diagnoses a year in England and Wales, of which, the figures suggest, around 720 would end in TOPFA. One of the most effective ways to reduce the incidence of these conditions is for women to take folic acid before they conceive, yet a comprehensive 2014 study showed that fewer than one in three women in the UK take folic acid prior to conceiving, a figure which has fallen since 2001. The shortfall in folic acid consumption is particularly pronounced among young women and women from BAME backgrounds – putting them at disproportionate risk of a fetal anomaly diagnosis. Current guidance and focus on independent supplementation with folic acid for women of childbearing age is therefore ineffective in preventing neural tube defects in wanted pregnancies. 

To reduce the prevalence of fetal anomaly diagnoses because of neural tube defects, and enable women to make their own decisions about their pregnancy – wanted or not – BPAS has long campaigned for the mandatory fortification of flour with folic acid.  

Mandatory fortification is also supported by the Independent Scientific Advisory Committee on Nutrition (SACN), the Food Standards Agency, the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal College of Midwives (RCM), and the Royal College of Paediatrics and Child Health (RCPCH). 

In the USA, mandatory fortification was introduced in 1998 and there was an ‘immediate and stable’ 28% reduction in prevalence of NTDs. Internationally, a systematic review and meta-analysis of 300 studies reported that the prevalence of spina bifida was lower in regions with mandatory rather than voluntary fortification (35 per 100,000 live births, stillbirths, and terminations of pregnancy compared to 52 per 100,000).

Only 55% of pregnancies in Great Britain are planned, which means that even if women are aware of guidance around folic acid, they are unlikely to be able to take the appropriate amount of folic acid before the point in pregnancy when the spinal cord, brain, and central nervous system finish developing c .23 days post-conception (c. 5 weeks’ gestation). The effect is particularly pronounced among young women where only 6% of women who became pregnant under the age of 20 take folic acid supplements before pregnancy – compared to 40% of women aged over 35. 

In September 2021, following a public consultation, the UK Government announced their intention to proceed with arrangements to require the mandatory fortification of non-wholemeal wheat flour with folic acid to help prevent neural tube defects in fetuses. 

The amount proposed will help to prevent between 15 and 22% of neural tube defects per year, whilst balancing current evidence around tolerable upper limits. 

The fortification of flour with folic acid is a straightforward public health intervention which could spare hundreds of women every year from the painful decision to end a wanted pregnancy after a diagnosis of a neural tube defect. Most fetal anomalies sadly are not preventable, but those related to folic acid deficiency can and must be reduced.  

After years of delay, we urge the government to bring forward this simple initiative as soon as possible in order to get the best pregnancy outcomes for as many women as possible.