title: Trends of selected malformations in relation to folic acid recommendations and fortification: an international assessment.
abstract: BACKGROUND
  Two crucial issues relative to the benefits and impact of folic acid in the prevention of birth defects are whether supplementation recommendations alone, without fortification, are effective in reducing the population-wide rates of neural tube defects (NTDs), and whether such policies can reduce the occurrence of other birth defects. Using data from 15 registries, we assessed rates and trends of 14 major defects, including NTDs, in areas with official recommendations or fortification to assess the effectiveness of recommendations and fortification on a wide range of major birth defects.
  
  
  METHODS
  We evaluated surveillance data through 2003 on major birth defects from population-based registries from Europe, North America, and Australia. All included ascertainment of pregnancy terminations (where legal). Trends before and after policies or fortification were assessed via Poisson regression and were compared via rate ratios.
  
  
  RESULTS
  Significant changes in trends were seen for NTDs in areas with fortification but not in areas with supplementation recommendations alone. For other major birth defects, there was an overall lack of major trend changes after recommendations or fortification. However, some significant declines were observed for select birth defects in individual areas.
  
  
  CONCLUSIONS
  Recommendations alone remain an ineffective approach in translating the known protective effect of folic acid in population-wide decline in NTD rates. Fortification appears to be effective in reducing NTDs. The effect on other birth defects remains unclear.
authors.affiliation: Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA.
authors.forename: Lorenzo D
authors.initials: LD
authors.lastname: Botto
authors.forename: Alessandra
authors.initials: A
authors.lastname: Lisi
authors.forename: Carol
authors.initials: C
authors.lastname: Bower
authors.forename: Mark A
authors.initials: MA
authors.lastname: Canfield
authors.forename: Nirupa
authors.initials: N
authors.lastname: Dattani
authors.forename: Catherine
authors.initials: C
authors.lastname: De Vigan
authors.forename: Hermien
authors.initials: H
authors.lastname: De Walle
authors.forename: David J
authors.initials: DJ
authors.lastname: Erickson
authors.forename: Jane
authors.initials: J
authors.lastname: Halliday
authors.forename: Lorentz M
authors.initials: LM
authors.lastname: Irgens
authors.forename: R Brian
authors.initials: RB
authors.lastname: Lowry
authors.forename: Robert
authors.initials: R
authors.lastname: McDonnell
authors.forename: Julia
authors.initials: J
authors.lastname: Metneki
authors.forename: Simone
authors.initials: S
authors.lastname: Poetzsch
authors.forename: Annukka
authors.initials: A
authors.lastname: Ritvanen
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Robert-Gnansia
authors.forename: Csaba
authors.initials: C
authors.lastname: Siffel
authors.forename: Claude
authors.initials: C
authors.lastname: Stoll
authors.forename: Pierpaolo
authors.initials: P
authors.lastname: Mastroiacovo
mesh_terms: D019587:Dietary Supplements / Q000592:standards; D005069:Evaluation Studies as Topic; D005260:Female; D005492:Folic Acid; D005527:Food, Fortified / Q000592:standards; D017408:Guidelines as Topic; D006801:Humans; D007391:International Cooperation; D008297:Male; D009436:Neural Tube Defects / Q000453:epidemiology* / Q000209:etiology / Q000517:prevention & control*; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D012042:Registries; D012189:Retrospective Studies
chemical_list: D005492:Folic Acid