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



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.

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  1. The NTD birth prevalence is the number of NTD-affected individuals among all births (live births and stillbirths) divided by the number of total babies born (live births and stillbirths) in a specified time and place. Births include termination of pregnancy after 20 weeks’ gestation. NTD rate is the number of NTD-affected babies from a birth or termination of pregnancy for congenital anomaly regardless of pregnancy gestation divided by the number of total babies born (live births and stillbirths) in a specified time and place.

  2. The NTD rate collection was incomplete in NSW.


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

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Authors and Affiliations



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.

Corresponding author

Correspondence to Sopany Saing.

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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.

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Saing, S., Haywood, P., van der Linden, N. et al. Real-World Cost Effectiveness of Mandatory Folic Acid Fortification of Bread-Making Flour in Australia. Appl Health Econ Health Policy 17, 243–254 (2019).

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