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Folic acid to reduce neonatal mortality from neural tube disorders Blencowe H; Cousens S; Modell B; Lawn JInt J Epidemiol 2010[Apr]; 39 Suppl 1 (Suppl 1): i110-21BACKGROUND: Neural tube defects (NTDs) remain an important, preventable cause of mortality and morbidity. High-income countries have reported large reductions in NTDs associated with folic acid supplementation or fortification. The burden of NTDs in low-income countries and the effectiveness of folic acid fortification/supplementation are unclear. OBJECTIVE: To review the evidence for, and estimate the effect of, folic acid fortification/supplementation on neonatal mortality due to NTDs, especially in low-income countries. METHODS: We conducted systematic reviews, abstracted data meeting inclusion criteria and evaluated evidence quality using adapted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Where appropriate, meta-analyses were performed. RESULTS: Meta-analysis of three randomized controlled trials (RCTs) of folic acid supplementation for women with a previous pregnancy with NTD indicates a 70% [95% confidence interval (CI): 35-86] reduction in recurrence (secondary prevention). For NTD primary prevention through folic acid supplementation, combining one RCT with three cohort studies which adjusted for confounding, suggested a reduction of 62% (95% CI: 49-71). A meta-analysis of eight population-based observational studies examining folic acid food fortification gave an estimated reduction in NTD incidence of 46% (95% CI: 37-54). In low-income countries an estimated 29% of neonatal deaths related to visible congenital abnormalities are attributed to NTD. Assuming that fortification reduces the incidence of NTDs, but does not alter severity or case-fatality rates, we estimate that folic acid fortification could prevent 13% of neonatal deaths currently attributed to congenital abnormalities in low-income countries. DISCUSSION: Scale-up of periconceptional supplementation programmes is challenging. Our final effect estimate was therefore based on folic acid fortification data. If folic acid food fortification achieved 100% population coverage the number of NTDs in low-income countries could be approximately halved. CONCLUSION: The evidence supports both folic acid supplementation and fortification as effective in reducing neonatal mortality from NTDs.|Dietary Supplements[MESH]|Female[MESH]|Folic Acid/*administration & dosage[MESH]|Food, Fortified[MESH]|Humans[MESH]|Incidence[MESH]|Infant, Newborn[MESH]|Male[MESH]|Neural Tube Defects/*mortality/*prevention & control[MESH]|Poverty[MESH]|Preconception Care[MESH]|Pregnancy[MESH]|Prenatal Care[MESH]|Primary Prevention[MESH]|Randomized Controlled Trials as Topic[MESH]|Recurrence[MESH]|Vitamin B Complex/*administration & dosage[MESH] |
