Status of prevention of neural tube defects post-folic acid fortification of cereal grains in South Africa.

Objective: Neural tube defects (NTD) are serious, life-threatening birth defects. Staple food fortification with folic acid (vitamin B₉) is a proven, effective intervention to reduce NTD birth prevalence. Mandatory food fortification with folic acid was implemented in South Africa (SA) in 2003. This article provides an overview of NTD birth prevalence in SA, pre- and post-fortification, and evaluates current folic acid fortification regulations.

Design: Fortification effectiveness data in SA were reviewed using published studies and national reports on NTD birth prevalence pre- and post-folic acid fortification. Current folic acid fortification regulations in SA were evaluated by experts.

Setting: Regulations were assessed using national health guidelines, legislation and regulations. NTD birth prevalence data were sourced from the published literature.

Participants: None.

Results: Significant reductions in the birth prevalence of spina bifida and anencephaly and improved maternal folate levels have been achieved following the introduction of folic acid fortification in SA. However, there is poor overall regulatory compliance in some instances and a gap in current regulations that excludes the fortification of cake flour in SA.

Conclusions: While the SA NTD birth prevalence has decreased by 30% post-fortification, the regulatory exclusion of cake flour fortification is a significant and growing issue. Proposed 2016 regulatory amendments to address this gap urgently require finalisation and enactment by government to prevent negating benefits achieved to date and to ensure continued improvement. Fortification monitoring requires strengthening to ensure widespread compliance with policies, particularly in underserved areas.