Since 1992, women of reproductive age have been advised to take an extra 0.4 mg of folic acid daily before pregnancy and during the first 12 weeks of pregnancy. Compliance with the recommendation has been examined in numerous studies conducted throughout the world. Knowledge of the appropriate use of folic acid for NTD prevention in women of childbearing age and in health workers increased markedly throughout the 1990s. Because folic acid can only work if it is taken before closure of the neural tube, the best indicator of periconcep-tional supplementation is the proportion of pregnant women who take a folic acid supplement before the pregnancy begins, and this proportion increased during the 1990s. In seven studies published from 1999 to 2003 and based on representative study samples in North America and Europe, the proportion of women reported as taking folic acid before pregnancy ranged from 33 to 49%, with a median of 36%. Supplementation is less common in unplanned pregnancies; in young, socially or educationally disadvantaged, and single mothers; and in those with no knowledge about the protective effect of folic acid. The most important predictor of nonsupplementation is unplanned pregnancy. Because unplanned pregnancy is very common (e.g., approximately half of all pregnancies are reported as being unplanned in the United States and Ireland), this factor constitutes the greatest logistical obstacle to planning optimal protection against NTD by periconceptional supplementation. The low supplementation rates reflect the relative lack of effectiveness of promotional campaigns as currently formulated. Public health programs promoting folic acid must be sustained and must pay particular attention to those at greatest risk of not supplementing.

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