Real-World Cost Effectiveness of Mandatory Folic Acid Fortification of Bread-Making Flour in Australia

  • Sopany SaingEmail author
  • Phil Haywood
  • Naomi van der Linden
  • Kathleen Manipis
  • Elena Meshcheriakova
  • Stephen Goodall
Original Research Article



In 2009, mandatory folic acid fortification of bread-making flour was introduced in Australia to reduce the birth prevalence of preventable neural tube defects (NTDs) such as spina bifida. Before the introduction of the policy, modelling predicted a reduction of 14–49 NTDs each year.


Using real-world data, this study provides the first ex-post evaluation of the cost effectiveness of mandatory folic acid fortification of bread-making flour in Australia.


We developed a decision tree model to compare different fortification strategies and used registry data to quantify the change in NTD rates due to the policy. We adopted a societal perspective that included costs to industry and government as well as healthcare and broader societal costs.


We found 32 fewer NTDs per year in the post-mandatory folic acid fortification period. Mandatory folic acid fortification improved health outcomes and was highly cost effective because of the low intervention cost. The policy demonstrated improved equity in outcomes, particularly in birth prevalence of NTDs in births from teenage and indigenous mothers.


This study calculated the value of mandatory folic acid fortification using real-world registry data and demonstrated that the attained benefit was comparable to the modelled expected benefits. Mandatory folic acid fortification (in addition to policies including advice on supplementation and education) improved equity in certain populations and was effective and highly cost effective for the Australian population.



Liz Chinchen (CHERE, UTS), Research Manager, assisted with the literature search.

Author Contributions

SS, PH, NvdL and SG designed the research; SS, PH, KM and EM conducted the research and performed the analysis; SS, PH and NvdL wrote the manuscript; and KM, EM and SG reviewed the manuscript. All authors read and approved the final manuscript.

Compliance with Ethical Standards


This study was funded by the Australian Health Ministers’ Advisory Council (AHMAC), Department of Health.

Conflict of interest

SS, PH, NvdL, KM, EM and SG have no conflicts of interest that are directly relevant to the content of this article. NvdL is now employed at AstraZeneca Netherlands.

Supplementary material

40258_2018_454_MOESM1_ESM.docx (28 kb)
Supplementary material 1 (DOCX 28 kb)


  1. 1.
    FSANZ. Proposal P295: Consideration of mandatory fortification with folic acid: Final Assessment Report. Food Standards Australia and New Zealand; 2006.Google Scholar
  2. 2.
    Rabovskaja V, Parkinson B, Goodall S. The cost-effectiveness of mandatory folic acid fortification in Australia. J Nutr. 2013;143(1):59–66.CrossRefGoogle Scholar
  3. 3.
    Dalziel K, Segal L, Katz R. Cost-effectiveness of mandatory folate fortification v. other options for the prevention of neural tube defects: results from Australia and New Zealand. Public Health Nutr. 2010;13(4):566–78.CrossRefGoogle Scholar
  4. 4.
    Access Economics. Cost benefit analysis of fortifying the food supply with folic acid. Food Standards Australia New Zealand; 2006.Google Scholar
  5. 5.
    Access Economics. Fortification of bread with folic acid. Food Standards Australia New Zealand; 2006.Google Scholar
  6. 6.
    Hilder L. Neural Tube Defects in Australia, 2007–2011: Before and after implementation of the mandatory folic acid fortification standard. New South Wales: University of New South Wales, National Perinatal Epidemiology and Statistics Unit; 2016.Google Scholar
  7. 7.
    FSANZ. Proposal P295 Consideration of mandatory fortification with folic acid: first review report Food Standards Australia and New Zealand; 2007.Google Scholar
  8. 8.
    Australian Health Ministers’ Advisory Council. The effectiveness and cost-effectiveness of mandatory folic acid and iodine fortification 2017.Google Scholar
  9. 9.
    Australian Institute of Health and Welfare. Monitoring the health impacts of mandatory folic acid and iodine fortification. Canberra: AIHW; 2016.Google Scholar
  10. 10.
    Sayed AR, Bourne D, Pattinson R, Nixon J, Henderson B. Decline in the prevalence of neural tube defects following folic acid fortification and its cost-benefit in South Africa. Birth Defects Res Part A Clin Mol Teratol. 2008;82(4):211–6.CrossRefGoogle Scholar
  11. 11.
    Romano PS, Waitzman NJ, Scheffler RM, Pi RD. Folic acid fortification of grain: an economic analysis. Am J Public Health. 1995;85(5):667–76.CrossRefGoogle Scholar
  12. 12.
    Llanos A, Hertrampf E, Cortes F, Pardo A, Grosse SD, Uauy R. Cost-effectiveness of a folic acid fortification program in Chile. Health Policy (Amsterdam, Netherlands). 2007;83(2–3):295–303.CrossRefGoogle Scholar
  13. 13.
    Kelly A, Haddix A, Scanlon K, Helmick C, Mulinare J. Cost-effectiveness of strategies to prevent neural tube defects. In: Gold M, Siegel J, Russell L, Weinstein M, editors. Cost-effectiveness in health and medicine. Oxford: Oxford University Press; 1996. p. 313–48.Google Scholar
  14. 14.
    Jentink J, van de Vrie-Hoekstra NW, de Jong-van den Berg LT, Postma MJ. Economic evaluation of folic acid food fortification in the Netherlands. Eur J Public Health. 2008;18(3):270–4.CrossRefGoogle Scholar
  15. 15.
    Grosse SD, Waitzman NJ, Romano PS, Mulinare J. Reevaluating the benefits of folic acid fortification in the United States: economic analysis, regulation, and public health. Am J Public Health. 2005;95(11):1917–22.CrossRefGoogle Scholar
  16. 16.
    Bentley TG, Weinstein MC, Willett WC, Kuntz KM. A cost-effectiveness analysis of folic acid fortification policy in the United States. Public Health Nutr. 2009;12(4):455–67.CrossRefGoogle Scholar
  17. 17.
    Grosse SD, Berry RJ, Mick Tilford J, Kucik JE, Waitzman NJ. Retrospective assessment of cost savings from prevention: folic acid fortification and Spina bifida in the U.S. Am J Prev Med. 2016;50(5 Suppl 1):S74–80.CrossRefGoogle Scholar
  18. 18.
    FSANZ. Monitoring the Australian population’s intake of dietary folic acid before and after mandatory fortification Canberra. 2016.Google Scholar
  19. 19.
    Catalyst Ltd. Report of stage 1: a review of compliance with, and enforcement impacts of the mandatory fortification of bread with folic acid and iodine. Department of Health; 2015.Google Scholar
  20. 20.
    Australian Bureau of Statistics. 3101.0—Australian demographic statistics, Jun 2015. 2015. Accessed 15 Apr 2016.
  21. 21.
    Australian Bureau of Statistics. 3301.0—Births, Australia, 2014. 2015. Accessed 15 Apr 2016.
  22. 22.
    Australian Bureau of Statistics. 3302.0.55.001—Life tables, States, Territories and Australia, 2012–2014. 2014. Accessed 15 Apr 2016.
  23. 23.
    Australian Government Department of Health. Guidelines for preparing a submission to the Pharmaceutical Benefits Advisory Committee (Version 5.0): Australian Government; 2016.Google Scholar
  24. 24.
    Macaldowie A, Hilder L. Neural tube defects in Australia: prevalence before mandatory folic acid fortification. Canberra: AIHW; 2011.Google Scholar
  25. 25.
    Wang Y, Liu G, Canfield MA, Mai CT, Gilboa SM, Meyer RE, et al. Racial/ethnic differences in survival of United States children with birth defects: a population-based study. J Pediatr. 2015;166(4):819.CrossRefGoogle Scholar
  26. 26.
    Siffel C, Wong LY, Olney RS, Correa A. Survival of infants diagnosed with encephalocele in Atlanta, 1979–98. Paediatr Perinat Epidemiol. 2003;17(1):40–8.CrossRefGoogle Scholar
  27. 27.
    Shin M, Kucik JE, Siffel C, Lu C, Shaw GM, Canfield MA, et al. Improved survival among children with spina bifida in the United States. J Pediatr. 2012;161(6):1132.CrossRefGoogle Scholar
  28. 28.
    Tilford JM, Grosse SD, Robbins JM, Pyne JM, Cleves MA, Hobbs CA. Health state preference scores of children with spina bifida and their caregivers. Qual Life Res Int J Qual Life Aspects Treat Care Rehabil. 2005;14(4):1087–98.CrossRefGoogle Scholar
  29. 29.
    Musci TJ, Caughey AB. Cost-effectiveness analysis of prenatal population-based fragile X carrier screening. Am J Obstet Gynecol. 2005;192(6):1905–12.CrossRefGoogle Scholar
  30. 30.
    Harris RA, Washington AE, Nease RF Jr, Kuppermann M. Cost utility of prenatal diagnosis and the risk-based threshold. Lancet. 2004;363(9405):276–82.CrossRefGoogle Scholar
  31. 31.
    Partridge JC, Sendowski MD, Martinez AM, Caughey AB. Resuscitation of likely nonviable infants: a cost-utility analysis after the Born-Alive Infant Protection Act. Am J Obstet Gynecol. 2012;206(1):49.CrossRefGoogle Scholar
  32. 32.
    National Hospital Cost Data Collection. National Hospital Cost Data Collection Cost Weights for AR-DRG Version 6.0x, Round 16 (2011–12), Public Hospital 2012. Accessed 15 Apr 2016.
  33. 33.
    Ouyang L, Grosse SD, Armour BS, Waitzman NJ. Health care expenditures of children and adults with spina bifida in a privately insured U.S. population. Birth Defects Res Part A Clin Mol Teratol. 2007;79(7):552–8.CrossRefGoogle Scholar
  34. 34.
    IHPA. National Hospital Cost Data Collection, Public Hospitals Cost Report, Round 19 (Financial year 2014–15).Google Scholar
  35. 35.
    Medicare Benefits Schedule. Medicare benefits schedule book: operating from 01 November 2014. Australian Government Department of Health; 2014.Google Scholar
  36. 36.
    Bamer AM, Connell FA, Dudgeon BJ, Johnson KL. Frequency of purchase and associated costs of assistive technology for Washington State Medicaid program enrolles with spina bifida by age. Disabil Health J. 2010;3(3):155–61.CrossRefGoogle Scholar
  37. 37.
    AIHW National Hospital Morbidity Database. Separation statistics by principal diagnosis (ICD-10-AM 8th edition), Australia, 2013–14. Accessed 15 Apr 2016.
  38. 38.
    Knies S, Severens JL, Ament AJ, Evers SM. The transferability of valuing lost productivity across jurisdictions. Differences between national pharmacoeconomic guidelines. Value Health. 2010;13(5):519–27.CrossRefGoogle Scholar
  39. 39.
    Australian Bureau of Statistics. 4433.0.55.006 Disability and Labour Force Participation: ABS; 2012. Accessed 08 June 2016.
  40. 40.
    Food and Drug Administration. Food additives permitted for direct addition to food for human consumption; folic acid. Final rule. Fed Regist. 2016;81(73):22176–83.Google Scholar
  41. 41.
    Parkinson B, Goodall S, Norman R. Measuring the loss of consumer choice in mandatory health programmes using discrete choice experiments. Appl Health Econ Health Policy. 2013;11(2):139–50.CrossRefGoogle Scholar
  42. 42.
    Molster C, Samanek A, Bower C, O’Leary P. A survey of folate knowledge and consumer behaviours in Western Australia prior to the introduction of mandatory food fortification. Austr N Z J Public Health. 2009;33(6):577–82.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Centre for Health Economics Research and EvaluationUniversity of Technology SydneySydneyAustralia
  2. 2.Erasmus School of Health Policy & ManagementErasmus University RotterdamRotterdamNetherlands

Personalised recommendations