Less than 20 percent of preventable birth defects of the brain and spine are being prevented worldwide via the proven means of fortifying wheat and maize flour with folic acid (vitamin B9), according to newly published research by scientists at the Emory University Rollins School of Public Health. While the percentage of prevention increased since the last biennial estimate, it is far below the prevention level that researchers believe is possible.

The Emory research is based on estimates on live births affected by spina bifida or anencephaly which are the most common of these birth defects, also called neural tube defects. The researchers estimate that in 2017, 50,270 cases or 18 percent of all folic acid-preventable spina bifida and anencephaly (FAP SBA). In 2015, an estimated 35,500 cases or 13 percent of all FAP SBA were prevented. The 2017 increase is largely due to Nigeria, a country with a high prevalence of spina bifida and anencephaly which added folic acid to its requirement for industrially milled wheat and maize flour in October 2015.

Preventing spina bifida and anencephaly also affects a country’s infant mortality rate. Other research indicates that among affected live births, 75 percent result in death before the child is five-years-old. In addition, that paper indicates that 50 percent of affected pregnancies end in terminations or stillbirths.

A randomized clinical trial published in 1991 unequivocally established that folic acid would prevent most birth defects of the brain and spine. Since then, women of child-bearing age have been encouraged to consume 400 micrograms of folic acid daily to reduce the risk of FAP SBA which occurs during the first four weeks of a pregnancy.

“During that period, most women are unaware of their pregnancies,” said Dr. Vijaya Kancherla, lead author, epidemiologist for the Center for Spina Bifida Prevention, and research assistant professor at Emory University’s Rollins School of Public Health. “Another complexity is that a high proportion of pregnancies are unplanned globally, and it is very likely that women are not on prenatal supplements in such situation. Adding folic acid to flour helps ensure that women consume adequate amounts of folic acid when they consume flour-based foods, irrespective of their pregnancy intention, and achieve primary prevention of spina bifida and anencephaly. With efficient fortification policies, countries have reduced their spina bifida and anencephaly rate to a low level of 0.5 per 1000 births. Thus, in countries like India that have a rate of 5 per 1000, fortification would likely prevent 90 percent of these birth defects and remarkably reduce child mortality.”

Godfrey Oakley, the senior author of the recent paper and director of Emory’s Center for Spina Bifida Prevention, refers to the modest global progress and inertia toward fortifying flour with folic acid as public health malpractice. The reaction to spina bifida prevention by the global community can be compared to the reaction to thalidomide in the 1950s. Thalidomide was used to treat nausea in pregnant women, but it caused about 10,000 cases of severe birth defects.

“That was universally seen as a tragedy, and public health officials stopped the use of thalidomide for pregnant women immediately,” Oakley said. “Each year, fortifying flour could prevent 20 times as many birth defects as were caused by the thalidomide, but we are not seeing the same public health reaction. Not fortifying is a huge missed opportunity.”