Leading public health experts are criticizing the United Kingdom government’s planned folic acid fortification policy as intentionally inadequate, warning that while new regulations will prevent approximately 200 cases of neural tube defects (NTDs) annually starting in 2026, fully effective fortification could prevent 800 cases, representing 80 percent of these devastating birth defects. The debate carries global implications as countries worldwide grapple with balancing public health effectiveness against policy caution.
Dr. Jonathan Sher, former Deputy Director of Queen’s Nursing Institute Scotland and founding partner of Scotland’s Coalition for Healthier Pregnancies, Better Lives, emerged as a prominent voice in the campaign for fully effective fortification through his columns in the International Journal of Birth and Parent Education (IJBPE). His advocacy reached a crescendo in recent articles co-authored with nine distinguished colleagues including Professor Sir Harry Burns, former Chief Medical Officer (CMO) for Scotland, and Professor Judith Stephenson, Co-Chair of UK Preconception Partnership.
The experts compare the UK government’s approach to administering only one stitch to close a wound requiring five, acknowledging the single stitch closes merely 20 percent of the injury while claiming it represents better than nothing and a good start. This odd and unacceptable partial solution is analogous to what the UK Government is pursuing on the fortification of some foods with folic acid to prevent Neural Tube Defects, they wrote in a 2024 IJBPE article.
Neural tube defects constitute major congenital malformations causing fetal deaths or serious lifelong, life-limiting disabilities including spina bifida and anencephaly. These conditions develop when the neural tube, which forms the baby’s brain, spinal cord and nervous system, malforms by the end of the fourth week of pregnancy, typically before most women realize they are pregnant. The defects lead to miscarriages, therapeutic terminations, stillbirths, neonatal deaths and permanent disabilities for surviving children.
Professor Sir Nicholas Wald of University College London (UCL) Institute of Health Informatics conducted landmark research in 1991 for the UK Medical Research Council (MRC) demonstrating that sufficient folic acid intake before and during the first month of pregnancy can prevent more than 80 percent of NTDs. That research, published in The Lancet over 30 years ago, established a daily intake of 4 milligrams of folic acid before and after conception achieves this protective effect.
Despite three decades of promoting individual supplementation, uptake remained too limited to significantly reduce overall NTD incidence while inadvertently widening inequalities, with less well-off prospective parents losing out. The recently published National Diet and Nutrition Survey revealed startlingly low folate status across the UK population between 2008 and 2019, with almost 90 percent of women of childbearing age below the level necessary to prevent NTDs.
The UK government announced in November 2024 that legislation will require millers and flour producers to fortify non-wholemeal wheat flour with folic acid from the end of 2026. While health advocates welcomed the long delayed move after decades of campaigning, critics immediately noted the government’s intentionally limited approach. By its own admission, the UK Government estimates its fortification plan would prevent only 18 to 22 percent of NTDs, according to public health expert Paul Haggarty.
The half-baked proposal adds Vitamin B9 only to non-wholemeal flour and only at very low levels, excluding those who consume wholemeal bread, gluten-free products or diets based on other grains such as rice or maize. This limitation proves particularly problematic in multicultural societies like the UK where diverse populations rely on various flour types. Countries with diverse populations such as the United States implemented wider approaches including multiple grain types.
Fully Effective Fortification can be achieved through either 4 milligrams of folic acid daily for months before and the month after pregnancy, or fortification at 1 milligram per 100 grams of flour and grains, according to Professor Wald’s research. The UK government’s planned level falls far below this threshold, settling for minimal fortification despite scientific evidence supporting higher levels.
The main rationale for timid fortification levels appears derived from outdated and disproven speculation regarding excessive folic acid exacerbating sequelae related to Vitamin B12 deficiency. However, distinguished researchers reviewing evidence prior to the UK government’s proposed policy concluded there is no evidence of harm arising from folic acid fortification at the higher levels needed to achieve fully effective fortification.
Fortification with folic acid has proven safe in more than 90 countries around the world implementing the policy. No country has ever documented adverse effects after evaluations, and no country has ever discontinued fortification after implementation, according to the Food Fortification Initiative. The United States, Canada, Australia and numerous other nations have successfully maintained folic acid fortification for decades with measurably positive outcomes.
The United States added folic acid to flour in 1998, resulting in dramatic reductions in NTD prevalence. Had the UK implemented similar fortification levels from 1998 onwards, an estimated 2,014 fewer NTD pregnancies would have occurred through 2012, according to research published in Archives of Disease in Childhood. The delay in implementation represents a missed opportunity that has caused and continues causing avoidable terminations of pregnancy, stillbirths, neonatal deaths and permanent serious disabilities.
Professor Wald’s September 2025 research, published in Archives of Disease in Childhood, resolved technical debates about fortification effectiveness by re-plotting the relationship between folate levels and neural tube defects on logarithmic scales. The continuous relationship showed each doubling of serum folate amounts to approximately halving the risk of neural tube defects. Both previous arithmetic analyses and new logarithmic interpretations demonstrate identical preventive benefits of higher serum folate levels.
A target serum folate concentration of 44 nanograms per milliliter would prevent approximately 80 percent of neural tube defects, aligning with the original MRC Vitamin Study results. This scientific clarity eliminates previous uncertainty about optimal fortification levels, leaving policy choices as the primary obstacle to fully effective prevention.
The financial and human costs of failing to prevent NTDs prove substantial. Those born with Fetal Alcohol Spectrum Disorders (FASD) were referred to as million dollar babies for decades, though the Government of Canada estimated direct costs associated with FASD over a lifetime at approximately 1.5 million dollars Canadian per person. While NTDs differ from FASD, the lifelong medical care, special education, mobility aids, home modifications and support services required by individuals with spina bifida impose comparable economic burdens.
More importantly, the human toll extends beyond economic calculations. Families receiving devastating news that their baby has anencephaly and will not survive, or learning their child faces lifelong complex disability from spina bifida, experience profound grief and challenging adjustments. Kate Steele, CEO of Shine, the charity providing specialist support for people affected by spina bifida and hydrocephalus, celebrated the forthcoming fortification while acknowledging it falls short of maximum prevention potential.
After more than 30 years of campaigning, Shine can finally celebrate the introduction of this very important public health initiative, Steele stated following the November 2024 announcement. However, the charity along with health experts continues advocating for enhanced fortification levels that would prevent four out of five cases rather than one out of five.
The UK is not alone in taking suboptimal approaches, with many countries limiting the range of fortified flours and grains while settling for fortification levels well below those proven safe and efficacious. Moldova stands as the only European country with mandatory folic acid fortification as of July 2023, though several nations plan implementation. Had folic acid fortification been implemented in European Union member states in 1998 simultaneously with the USA, an estimated 19,500 neural tube defects could have been prevented as of 2021.
Professor Chris Whitty, England’s CMO, supported the fortification initiative while emphasizing continued importance of supplements. The fortification of flour is a simple and effective way to help reduce cases of neural tube defects, although it is important that women who are pregnant or intending to become pregnant continue to take folic acid supplements before and during the first 12 weeks of pregnancy, he stated.
The National Health Service (NHS) recommends women trying for babies take folic acid supplements approximately three months before conception and for at least 12 weeks after becoming pregnant. This recommendation will remain after new regulations take effect. However, with an estimated half of all UK pregnancies unplanned, many women miss this critical window. The regulations aim to provide higher baseline folic acid intake better protecting babies in all scenarios.
Dr. Sher’s final IJBPE column emphasizes that Day One, typically considered the birth of a baby and start of the Critical 1,001 Days framework, often proves too late for preventing conditions determined during preconception and prenatal periods. When Professor Mary Nolan created the IJBPE a dozen years ago, it was both a reflection of and a major contributor to the advancement of the Critical 1,001 Days movement, Sher wrote. In recent years, the IJBPE has gone a crucial step further to become a leader in joining the dots among the Three Ps: preconception, prenatal and parenting.
The preconception period encompasses three key stages according to Sher’s framework: socialization and habit formation during childhood and adolescence when health habits develop, decision making about parenthood covering wide age ranges and situations, and getting ready for pregnancy between the decision to conceive and actual conception. This final stage deserves equal status and attention alongside contraception and pregnancy rather than remaining the pebble between two boulders.
Nearly half of all pregnancies remain unplanned, mistimed or accidental, leading to some terminations that are not medically necessary but have become de facto forms of birth control. When pregnancies are ill-prepared for, preconception and interconception health, education and care are either precluded or dramatically limited. These pregnancies face greatest risk of unhappy endings, while happy endings are most likely secured by actions taken and dangers avoided before pregnancy.
The debate extends beyond technical questions about fortification levels to fundamental issues about governmental responsibility in public health. Why accept a 20 percent solution to a longstanding health problem causing many fetal deaths and major birth defects when a safe and more effective 80 percent solution is within grasp? Critics characterize the choice as governmental action limiting medications to quarter doses when full doses have been proven safe and more effective through robust research and longstanding clinical experience.
Experiencing unwelcome pregnancy outcomes proves personally painful, professionally unwelcome and economically counterproductive. Settling for preventing only 20 percent of NTDs through suboptimal fortification means tragic consequences will predictably occur four times more often than with fully effective fortification. As decision time approaches, advocates insist it is not yet too late for government to change direction, choose to do the right thing and do it right.
Ghana and other African nations face similar policy choices regarding folic acid fortification. While Ghana has made strides in maternal and child health, NTD prevention through food fortification remains underutilized across the continent. The UK debate offers valuable lessons for developing nations considering fortification policies. Implementing fully effective fortification from the outset avoids the policy inertia and incremental approaches that have characterized UK and European experiences.
The playing field must be made as level as possible during the pre-pregnancy period to ensure a much higher proportion of babies have the best start in life that collective wit, will and resources can enable, Sher emphasized. This work grounds itself in fundamental public health principles of promoting wellbeing, creating health and preventing harm. Thousands of lives and life chances each year hang in the balance when governments choose between adequate and optimal fortification levels.
