Folic acid supplementation in Europe: a EUROCAT report

Background: Neural Tube Defects (NTDs) are among the most commonly occurring fetal abnormalities and although it has been established for a decade that periconceptional folic acid supplementation reduces the risk of both recurrence and of first occurrence, implementation has proved to be and enormous public health challenge. This has been met in a variety of ways in different parts of the world with varying degrees of success. The aim of this study was to establish what action was being taken across Europe in relation to periconceptional folic acid supplementation and what effect this was having on the prevalence of NTDs in Europe. Methods: EUROCAT is a network of 36 congenital anomaly registries in Europe collaborating in the epidemiological surveillance of congenital anomalies. Representatives from 17 countries participating in EUROCAT agreed to provide information about the folic acid situation in their country, and NTD rates were extracted form Central Registry database for 1980-1999. Findings presented here are preliminary. Results: At the beginning of 2001, official governmental recommendation that women planning a pregnancy should take 0.4 mg of folic acid supplementation daily was in operation in ten of the 17 countries. The earliest of those countries to introduce an official supplementation policy was the UK in 1992 and the latest was Spain in 2001. In the remaining seven participating countries, no official government recommendation about supplementation was in place, however, professional bodies within a subset had in fact recommended supplementation. While foods fortified with folic acid are available in many of the countries surveyed, only Germany has legislation covering fortification (100 g of grain must be fortified with not less than 30 μ g of folic acid). Mandatory fortification is currently under consideration in Denmark, Switzerland and the United Kingdom. Only six countries had official health education initiatives: UK, Ireland, France, Netherlands, Norway and Denmark. Studies in most countries suggest that the majority of women remained unaware of the protective effect of folic acid and only a tiny minority took it at the appropriate time. Women in Ireland, the UK and Norway were found to be more likely to know about and take supplementation. Commencement of folic acid supplementation may be affected by the mother's approach to "planning" pregnancy. In most countries, it is not known what percentage of pregnancies are "planned". In Germany, a number of studies found that between 66-72% of pregnancies were "planned", estimates were found to be lower elsewhere. The prevalence of NTDs (including terminations) has not shown any steady decline in the 1990s across Europe. Conclusions: The potential for preventing neural tube defects by periconceptional folic acid supplementation is still far from being fulfilled in Europe.