September 13–19, 2026 · Executive leadership brief
Make prevention reachable before the earliest clinical window closes
National Folic Acid Awareness Week is a practical test of whether a health system can connect public information, preconception care, supplement access, risk-sensitive clinical guidance, and population surveillance before pregnancy recognition is expected to carry the whole burden.
The 2026 observance runs September 13–19. Its familiar message about folic acid and neural tube defect prevention remains important, but awareness alone is not an operating model. The clinically relevant timing begins before many people know they are pregnant. That makes prevention dependent on routine primary care, reproductive and sexual health services, pharmacy access, respectful communication, reliable supply, affordable options, clinical decision support, and public policy.
For healthcare executives, the leadership question is not simply whether educational material was distributed. It is whether eligible people were reached in time, received understandable and appropriate counseling, could act on the plan, and had a route for questions or higher-risk assessment. The evidence reviewed for this brief supports a layered approach while also showing substantial uncertainty across countries, study designs, supplements, fortification policies, and outcome definitions.1, 4, 5, 16
Prevention and timing
Treat preconception timing as a system design requirement
Neural tube development occurs early. A service model that waits for the first prenatal visit can therefore miss part of the prevention window. A 2026 best-evidence summary reviewed 17 guidelines, expert consensuses, recommended practices, and best practices. The authors organized 14 evidence statements around risk, neural tube closure, timing and dosage, diet and tablets, and testing. Their central operational implication was to begin appropriate supplementation before conception and continue through early pregnancy, with clinical recommendations varying by risk. The review is a synthesis rather than a new trial, and it focused particularly on settings without mandatory fortification.5
That timing challenge changes who owns the work. Obstetric services cannot carry it alone. Primary care, pediatrics during adolescent transition, pharmacy, emergency care, behavioral health, bariatric and metabolic services, genetics, neurology, and community partners may all encounter people who could benefit from respectful, clinically appropriate preconception information. The system also needs a safe response when a person is not planning pregnancy, does not wish to discuss reproductive goals, cannot use a standard recommendation, or has a condition or medication that requires specialist review. A reliable pathway offers information without coercion and preserves individual choice.
Population biomarker studies make the access problem visible, but their local estimates should not be imported as U.S. prevalence. In a 2026 facility-based cross-sectional study of 400 first-trimester pregnant women in five hospitals in Tigray, Ethiopia, 395 participants had red blood cell folate concentrations below the threshold used by the investigators for optimal neural tube defect prevention. Most also did not meet the study’s minimum dietary diversity threshold. Because the setting had unusually high neural tube defect risk, the study was cross-sectional, and only five participants were classified as folate sufficient, it cannot estimate the burden in another health system or prove that one intervention will correct it.1
A 2025 cross-sectional biomarker survey of 761 nonpregnant, nonlactating women of reproductive age in one region of Tanzania found red blood cell folate insufficiency in 39.8 percent. The urban prevalence was lower than the rural prevalence, and the authors estimated population neural tube defect risk from biomarker status. Those findings support the value of population-level surveillance and geographic stratification. They do not establish an individual diagnosis, a U.S. benchmark, or a causal effect of urban residence.13
Costa Rica surveillance signals before and after national folic-acid food fortification
| Surveillance period | Neural tube defect prevalence | Unit |
|---|---|---|
| Pre-fortification, 1987–1998 | 11.82 | Per 10,000 live births |
| Post-fortification, 2010–2020 | 5.52 | Per 10,000 live births |
Questions for the executive baseline
- Which services routinely reach people before pregnancy, and where is preconception information absent or inconsistent?
- What local clinical policy governs standard counseling, higher-risk review, contraindications, referral, and documentation?
- Can a person obtain an affordable, appropriate product without a new appointment, transportation barrier, or confusing handoff?
- Which populations are least likely to be reached early, and how do leaders know?
- What outcome can improve within 90 days without claiming that the health system changed birth-defect prevalence?
The outcome question matters. A 2026 prospective cohort analysis from premarital health examinations in two Chinese counties explored supplementation, diet, folate status, and time to pregnancy among 1,475 women. Only 24 reported folic-acid supplementation at baseline. Supplementation showed a potential positive association with fecundability in joint models, but the very small exposed group and data collected from 2009 to 2012 make the estimate uncertain and context dependent.2 Executives should not convert that signal into a fertility promise. The immediate organizational objective is a reliable, equitable prevention process.
Operating system
Connect reach, clinical governance, access, and follow-through
Folic-acid prevention spans boundaries that healthcare organizations often manage separately. Marketing may produce awareness content. Primary care may document pregnancy intention. Pharmacy may manage the available products. Obstetrics may maintain risk-specific clinical guidance. Population health may work with community partners. Quality may monitor documentation, while analytics may lack a shared denominator. If each function completes its own task but the person cannot move through the route, the campaign has activity without reliability.
The pathway must also distinguish population communication from individual clinical decision-making. Public information can explain why the timing matters and where to get help. It should not substitute for a clinician’s assessment of medication exposure, previous pregnancy history, nutrition, malabsorption, comorbidity, or other factors that may change the plan. A 2025 meta-analysis of 38 studies across 14 countries found lower maternal vitamin B12 levels in neural tube defect cases than controls, including analyses where folate levels did not differ significantly. The studies were heterogeneous and largely observational, so the result supports broader clinical awareness, not a universal testing or supplementation rule.12
The preconception folic-acid prevention operating system
A closed prevention pathway has six observable steps
- 1Reach respectfullyOffer timely information without assuming pregnancy intention
- 2Confirm contextIdentify goals, current use, access needs, and questions
- 3Apply guidanceUse approved policy and route higher-risk situations for review
- 4Enable accessResolve affordability, availability, language, and navigation barriers
- 5Verify understandingUse plain language, teach-back, and a documented next step
- 6Learn and improveReview completion, variation, exceptions, and feedback
Closing the loop requires a named receiving owner. A screening question that identifies a need but offers no route creates documentation, not prevention. A recommendation that depends on the person finding an affordable product without support transfers system complexity to the patient. A referral that is not acknowledged leaves the original clinician uncertain about completion. Executives should make the handoff visible, specify the expected response time, and decide what happens when the normal route fails.
The organization should also define the limits of routine testing and claims. The 2026 evidence summary advised against routine folate testing in the populations and guidance it synthesized.5 A separate review of pregnant women with excess weight argued for monitoring selected biomarkers and tailored protocols, but only eight European studies met inclusion criteria and adherence to existing recommendations was very low.14 Those differences demonstrate why a local multidisciplinary clinical-governance group should reconcile evidence, applicable guidelines, formulary, and referral criteria rather than letting a campaign improvise care.
Reach, literacy, and equity
Measure who can act, not only who saw the message
Knowledge is not one variable. A 2026 cross-cultural instrument-development study surveyed 538 women of reproductive age in Thailand and Yemen. The attitude scale showed strong internal consistency in both groups, while knowledge performance differed by item and the Yemeni knowledge section had lower internal consistency. The study produced a research instrument, not a universal scorecard, and used an online sample with substantially different group sizes.3 Its operational lesson is useful: leaders should test specific understanding in the language and context where an intervention will be used.
A 2025 Polish online survey found almost universal general awareness among 188 pregnant or recently pregnant participants, yet detailed knowledge varied. Women with infertility more often recognized folate forms, understood selected genetic concepts, and reported starting supplementation at least three months before conception. The sample was small, health engaged, and deliberately balanced by infertility status, so it cannot estimate awareness in the wider population. It shows why a high headline awareness rate can coexist with meaningful differences in timing and understanding.7
Health literacy can affect whether information becomes action. In a 2025 Hungarian cross-sectional study of 124 pregnant women, roughly half had problematic health literacy on each of two validated tools. Before pregnancy, 58.87 percent reported not taking folic-acid supplements, compared with 31.45 percent during pregnancy. The convenience and cross-sectional design cannot determine causality, and pregnancy-period recall may introduce error. The pattern nevertheless reinforces the need to reach people before pregnancy with usable instructions and to test comprehension rather than documenting education delivered.8
Equity becomes clearer when the denominator and stratifiers are explicit. A secondary analysis of 12,455 participants in the 2017 Indonesia Demographic and Health Survey found that 59.0 percent of urban women and 47.8 percent of rural women reported taking iron-folic acid supplementation for at least 90 days. Education and wealth concentration indices indicated pro-educated and pro-rich inequalities overall, although patterns differed in rural analyses. The study combined iron and folic acid, relied on self-report, and examined an antenatal program in Indonesia. It should not become a U.S. performance threshold. It demonstrates how a single average can hide place, education, wealth, internet access, decision-making, and care-use differences.15
A U.S. population analysis using CDC WONDER natality data from 2016 through 2023 found differences in a combined set of congenital anomalies across maternal age, diabetes, tobacco use, body mass index, race, and other factors. In 2023, the combined prevalence of the selected anomalies was 3.3 per 1,000 singleton live births. Because the outcome grouped multiple anomalies with different causes and the design relied on surveillance data, the results cannot be attributed specifically to folate or a single intervention.6 The executive implication is to connect preconception prevention with a broader equity and chronic-disease strategy while keeping outcome definitions precise.
Reach
Define the eligible population and identify which settings make contact before pregnancy. Report the proportion offered information, not the number of impressions.
Understanding
Use plain language, qualified language support, accessible formats, and teach-back. Measure comprehension on a small sample before broad release.
Access
Document price, availability, transportation, pharmacy hours, coverage, disability access, and a safe route for clinical questions.
Follow-through
Track whether the next step was completed or acknowledged, while recognizing that noncompletion may expose a system barrier rather than patient refusal.
Stratification should be purposeful and privacy conscious. At minimum, leaders can examine service location, language, payer, geography, and age bands when cell sizes permit. Additional variables should be selected with community input and a clear improvement purpose. Small numbers need suppression or aggregation. The aim is not to profile individuals. It is to identify where the pathway is less reachable or less reliable and to redesign that part of the system.
Implementation barriers
Do not make awareness compensate for broken infrastructure
Campaigns are often asked to solve problems created by supply, policy, workflow, and trust. A 2025 bottleneck analysis of an iron and folic acid supplementation program in Pakistan included 33 key-informant interviews and 32 focus groups across four provinces and two federally administered regions. Participants described forecasting, procurement, distribution, funding, administrative delay, health-worker support, affordability, social norms, and trust as connected barriers. Because it was qualitative, combined iron and folic acid, and examined one national program, it does not quantify which barrier caused which outcome. It demonstrates that a counseling message can fail when the product is unavailable or the worker delivering the message has repeatedly been undermined by stockouts.9
Fortification policy has similar implementation dependencies. A 2023 review organized eight barriers and seven facilitators for mandatory folic-acid fortification across individual, contextual, and external domains. It emphasized policymaker knowledge, stakeholder partnership, reach, adoption, implementation, and scale.16 A 2025 evidence-based viewpoint argued that India’s permitted fortification levels were far below World Health Organization recommendations for the stated consumption context. It was a policy analysis, not an outcome evaluation, so its projected impact depends on assumptions about production, consumption, compliance, and surveillance.10
Voluntary policy may not produce the same reach as mandatory implementation. A 2023 all-payor claims study identified more than 2.5 million U.S. pregnancies from 2016 through September 2020 and used a Bayesian structural time-series model to evaluate the period after voluntary corn masa flour fortification was authorized. The investigators found no significant reduction in neural tube defect rates in predominantly Hispanic ZIP codes or overall. Claims coding, ZIP-code composition, product uptake, the short post-policy period, and the start of the COVID-19 pandemic limit interpretation.17 The study does not show that fortification is ineffective. It shows that authorization without verified adoption and exposure may not produce a detectable population result.
A 2025 systematic review and decision analysis in Bangladesh estimated neural tube defect prevalence from 11 studies and modeled combinations of supplementation, fortification, and arsenic reduction. The model projected that fortification would outperform supplementation unless supplement adherence exceeded 90 percent. This was a decision model built from multiple assumptions, not a randomized comparison of national strategies.11 Executives can use such models to test scenarios and identify sensitive assumptions, but they should not present modeled effects as observed local outcomes.
Contributors to a delayed or fragmented prevention pathway
The practical response is to observe the work before adding another alert. Interview patients and staff in the settings where the pathway should start. Follow a small sample of referrals. Check stock and price at the actual pharmacies people use. Review whether portal content is understandable without clinical background. Ask clinicians which situations create uncertainty and whether they can reach the right expert. Then choose the smallest change that removes a verified barrier.
Governance must protect against overreach. A 2026 critical narrative review argued that historical fortification comparisons may be confounded by socioeconomic change and raised ethical and policy questions about universal exposure.4 Its conclusions differ from reviews that characterize mandatory fortification as highly effective.16 The disagreement should be visible. Boards do not need false certainty. They need transparent review of evidence quality, benefits, possible harms, regulatory authority, alternatives, implementation fidelity, and surveillance.
Measurement and governance
Pair process reliability with equity, burden, and learning
Neural tube defect prevalence is a vital population outcome, but it is not a practical 90-day hospital improvement measure. The event is uncommon, definitions and ascertainment vary, and multiple factors influence risk. A short campaign also cannot reasonably claim a causal population effect. Leaders should instead measure the pathway they control while keeping long-term public-health surveillance connected to policy.
A useful dashboard starts with the eligible denominator and the point of contact. It then shows whether the person was offered information, whether the conversation was documented according to policy, whether a higher-risk situation reached the designated reviewer, whether access barriers were resolved, and whether the next step was acknowledged. Each measure needs an owner, cadence, exclusions, data source, and interpretation note. Rising referrals, for example, may indicate better recognition rather than greater underlying risk.
Candidate measures for a closed prevention pathway
| Domain | Candidate measure | Required denominator or definition | Owner + cadence | Interpretation limit |
|---|---|---|---|---|
| Reach | Eligible encounters offered timely preconception information | Defined services, ages, exclusions, and contact types | Primary care operations, monthly | Offer does not establish understanding or action |
| Clinical reliability | Higher-risk questions acknowledged by the designated reviewer | Referrals meeting local policy and acknowledgment window | Clinical governance lead, monthly | More referrals may reflect safer recognition |
| Understanding | Sampled counseling encounters with successful teach-back | Audited encounters, script, and scoring rule | Education + quality, monthly | Observed samples may not represent all encounters |
| Access | Documented barriers with a closed resolution or warm handoff | Barrier definition and acceptable closure states | Population health + pharmacy, monthly | Closure does not prove continued use |
| Equity | Completion gap across selected strata | Same pathway definition with privacy-safe groups | Analytics + equity, quarterly | Small cells and missing data can distort variation |
| Supply | Days selected low-cost options are available at partner sites | Named products, sites, and stock-check method | Pharmacy operations, weekly | Availability does not establish affordability or suitability |
| Burden | Median staff time and extra clicks for the pathway | Observed sample and start-stop definition | Improvement team, each test | Efficiency must not replace respectful counseling |
The dashboard should be paired with narrative. What barrier did patients and staff identify? What changed? Which populations benefited, and which did not? What uncertainty remains? What unintended burden appeared? What decision is required? An executive team can use a monthly review to remove policy or resource barriers. Frontline teams need faster feedback showing whether their reports changed the process. Community partners should receive a plain-language summary of what the organization learned.
Use one evidence discipline across all levels
At the encounter: Make the next step and receiving owner visible. Record unresolved access or clinical questions without forcing a person into a reproductive plan.
Each week: Review exceptions, stock, referral delay, staff burden, and patient feedback. Correct problems that can be fixed without waiting for a quarterly committee.
Each month: Examine completion and variation by service and selected equity strata. Review a small sample of records and conversations so documentation counts do not become the only truth.
Each quarter: Reconcile clinical guidance, community input, pharmacy availability, policy changes, and surveillance findings. State what the organization knows, what it does not know, and which decision comes next.
Implementation
Use the observance to launch one 90-day prevention-reliability cycle
The most credible observance commitment is specific enough to finish. Select one setting with meaningful preconception reach, such as primary care, a community pharmacy partnership, a reproductive-health service, or a digital intake pathway. Start with a small denominator. Confirm the clinical policy. Map the current route. Listen to people who did and did not complete the next step. Then test one change with explicit stop, escalation, and learning criteria.
A 90-day prevention-pathway reliability cycle
Authorize and listen
Name the sponsor, clinical governance lead, operational owner, patient-community partners, and analytic support. Select one service and one population. Interview staff and patients about timing, language, price, supply, referral, and follow-through. Confirm what the project will not do.
Map and baseline
Map the current pathway from first contact through acknowledged next step. Define eligible encounters, exclusions, measures, and equity cuts. Observe the work directly. Check product availability and staff time. Reconcile public messages with approved clinical guidance.
Co-design and test
Test one change, such as a better intake prompt, a warm pharmacy handoff, a plain-language script, or a faster higher-risk review route. Use teach-back and gather feedback. Track burden, exceptions, and unintended consequences. Stop or revise the test if clinical or equity concerns emerge.
Measure and decide
Compare process results with the baseline and review qualitative experience. State uncertainty and missing data. Decide to adopt, adapt, expand, or stop. Report the decision to staff, patients, and partners, including the next review date.
Connected leadership resources
Continue the work beyond the observance
Scholarly references
Evidence reviewed
Peer-reviewed literature was identified through the University of Phoenix Library’s nursing and medical research collections, limited to the most recent five years available and reviewed newest first. The public bibliography links to DOI records, not to the private research platform.
- Berihu, B. A., Mekonen, H. K., Mulugeta, A., et al. (2026). High prevalence and associated factors of red blood cell folate deficiency among first-trimester pregnant women in a neural tube defect high-risk region of Tigray, Northern Ethiopia. PLOS ONE, 21(8), e0356720. https://doi.org/10.1371/journal.pone.0356720
- Nie, Y., et al. (2026). Preconception folate status, dietary intake, supplementation, and time to pregnancy among women in a premarital health examination cohort. Nutrients, 18(14), 2238. https://doi.org/10.3390/nu18142238
- Al-Qaari, M., et al. (2026). Cross-cultural assessment of knowledge and attitudes toward folic acid: Instrument development and validation in Thailand and Yemen. PLOS ONE, 21(7), e0352966. https://doi.org/10.1371/journal.pone.0352966
- Westmark, C. J. (2026). Reassessing mandatory folic acid fortification for neural tube defect prevention: Evidence, uncertainty, and policy implications. Nutrients, 18(11), 1758. https://doi.org/10.3390/nu18111758
- Li, J., Chen, B., Liu, N., et al. (2026). Best evidence summary of folic acid supplementation for prevention of neural tube defects in women of childbearing age. Nutrients, 18(4), 641. https://doi.org/10.3390/nu18040641
- Ali, H., et al. (2026). A population-based study of U.S. trends in selected congenital anomalies (2016–2023) and socio-demographic disparities: A CDC WONDER analysis. Children, 13(2), 192. https://doi.org/10.3390/children13020192
- Barbarska, O., et al. (2025). Folate supplementation awareness among women of reproductive age in Poland: Focus on active forms and updated national recommendations. Nutrients, 17(24), 3881. https://doi.org/10.3390/nu17243881
- Csölle, I., et al. (2025). Health literacy of pregnant women and its association with methyl-group donor intake and folic acid supplementation: A cross-sectional study. BMC Public Health, 25, 3844. https://doi.org/10.1186/s12889-025-25239-x
- Ghur, R., et al. (2025). A bottleneck analysis of iron and folic acid supplementation program in Pakistan. Maternal & Child Nutrition, 21(3), 1–31. https://doi.org/10.1111/mcn.13797
- Kancherla, V., et al. (2025). Food fortification ineffective in preventing neural tube defects in India due to regulation promoting inadequate levels of folic acid and vitamin B12. Birth Defects Research, 117(7), e2498. https://doi.org/10.1002/bdr2.2498
- Wei, X., et al. (2025). Comparing folic acid interventions and arsenic reduction strategies for neural tube defect prevention in Bangladesh: A systematic review and decision analysis. Birth Defects Research, 117(6), e2494. https://doi.org/10.1002/bdr2.2494
- Nie, Y., et al. (2025). Beyond folate: The emerging role of maternal vitamin B12 in neural tube development. Nutrients, 17(12), 2040. https://doi.org/10.3390/nu17122040
- Mai, C. T., et al. (2025). Folate and vitamin B12 status among non-pregnant, non-lactating women of reproductive age and predicted risk for neural tube defects, Morogoro Region, Tanzania. Maternal and Child Health Journal, 29(5), 591–598. https://doi.org/10.1007/s10995-025-04046-1
- Loperfido, F., et al. (2025). Folic acid supplementation in European women of reproductive age and during pregnancy with excessive weight: A systematic review. Reproductive Health, 22, 13. https://doi.org/10.1186/s12978-025-01953-y
- Paramashanti, B. A., et al. (2024). Social determinants and socioeconomic inequalities in adherence to antenatal iron-folic acid supplementation in urban and rural Indonesia. Rural and Remote Health, 24(4), 24–34. https://doi.org/10.22605/RRH8722
- Ghotme, K. A., et al. (2023). Barriers and facilitators to the implementation of mandatory folate fortification as an evidence-based policy to prevent neural tube defects. Child’s Nervous System, 39(7), 1805–1812. https://doi.org/10.1007/s00381-023-05944-x
- Khalid, S. I., et al. (2023). The impact of voluntary folate fortification of corn masa flour on U.S. pregnancies complicated by neural tube defects. Child’s Nervous System, 39(7), 1813–1819. https://doi.org/10.1007/s00381-023-05945-w
- Benavides-Lara, A., et al. (2023). Integrated surveillance strategy to support the prevention of neural tube defects through food fortification with folic acid: The experience of Costa Rica. Child’s Nervous System, 39(7), 1743–1754. https://doi.org/10.1007/s00381-023-05837-z
Editorial boundary: This executive brief supports governance, quality, equity, communication, and operational planning. It does not replace individual medical advice, approved clinical guidance, medication review, professional scope, organizational policy, public-health authority, or qualified clinical judgment.