A forgotten supplement: why fewer women are taking folic acid before pregnancy

In December 2021, a High Court judge ruled in favour of Evie Toombes, who was born in November 2001 with a neural tube defect^​1​. Her mother had attended an appointment with her GP in February 2001 for preconception counselling. The court accepted her account that her mother came away from the appointment believing folic acid supplements were unnecessary if she had a healthy diet, which she did.

The GP could not recall the consultation from so long ago, saying he “relied on his usual practice” and notes from the time, which read: “Preconception counselling. adv. Folate if desired discussed.” The judge found its brevity made his evidence less reliable than it might have been and concluded that her dietary intake would have had to have been “very good” for supplements to be unnecessary.

Had Toombes’ mother been advised differently, she would have delayed conception to build up her folic acid intake and a “healthy” child would have been born, the High Court found.

Two decades on, guidance from the World Health Organization^​2​, the National Institute for health and Care Excellence^​3​ and the NHS^​4​ is unambiguous: women who may become, or are planning to become, pregnant should take daily folic acid supplements of 400mcgs, until 12 weeks of gestation.

However, a paper published on 9 August 2026 from researchers at the University of Southampton describes a “concerning” drop in the number of women taking folic acid supplements before pregnancy^​5​. NHS maternity statistics show the proportion of women in England taking the supplements fell from 26% in 2020/2021 to below 20% in 2024/2025^​6​.

Keith Godfrey, professor of epidemiology and human development at the University of Southampton and one of the researchers, told The Pharmaceutical Journal that while there is “no certainty” about what is driving the decline, he suspects the issue has “fallen off the agenda” for healthcare providers, including pharmacists, GPs and in secondary care.

Part of that may be a consequence of the publicity around the government’s 2024 announcement that non-wholemeal wheat flour will be fortified with folic acid from the end of 2026, he suggests.

This is a move that the government says is intended to prevent around 200 cases of neural tube defects (NTDs) each year. Godfrey highlights that the risk is that some women may have taken this to mean a supplement is not necessary.

However, he notes: “The level of fortification will not achieve sufficient status in the mother to properly prevent birth defects,” adding that this “has not been properly recognised”.

Amira Guirguis, chief scientist at the Royal College of Pharmacy, says: “Fortification should be seen as a safety net at population level, rather than a replacement for supplementation.”

In its announcement, the government stated that the NHS recommendation to take folic acid for three months before conception and the first 12 weeks of pregnancy “will remain in place” after the new regulations.

Fortification is designed to raise baseline intake across the population — reducing NTDs by an estimated 20% — rather than to deliver the recommended daily dose. This is important as about half of UK pregnancies are unplanned, so many women may not be taking the supplement when it counts.

Godfrey points to low public awareness on preconception advice, compounded by reduced face-to-face contact with healthcare providers about contraception and sexual health since the COVID-19 pandemic, which has narrowed opportunities for the conversation to happen at all where people would receive the advice to take folic acid.

Why folic acid?

Folic acid is an artificial form of vitamin B9 or folate. Taken in the earliest weeks of pregnancy as a supplement, it supports the development of a baby’s brain, skull and spinal cord, lowering the risk of NTDs, such as spina bifida, where a baby’s spine and spinal cord do not fully develop, and anencephaly, where a baby’s brain doesn’t form properly in the womb.

Guirguis says that those planning a pregnancy should ideally start taking folic acid supplements around three months beforehand. “Timing is really important because the neural tube develops very early in pregnancy, often before someone knows they are pregnant,” she adds.

“So, starting folic acid only once pregnancy is confirmed can mean missing an important part of that preventive window.”

In their paper, the Southampton researchers found the proportion of women starting supplements once pregnancy is confirmed has risen slightly, from 65% to 69%, but by then it is generally “too late” to prevent NTDs because the neural tube has usually closed by the fourth week of gestation.

Women at higher risk of having a baby with a NTD are advised to take 5mg daily. According to Guirguis, this includes those with a previous pregnancy affected by a NTD, those with certain medical conditions, or “those taking medicines that can affect folate absorption or metabolism”.

She stresses the importance of distinguishing “between groups where uptake is lower and people who are clinically at higher risk of a pregnancy affected by a neural tube defect”.

Uptake varies considerably: in 2023–2024, statistics from the Office for Health Improvement and Disparities found that 10.1% of women in the most deprived areas of England took folic acid before pregnancy, compared with 27% in the least deprived^​7​. Uptake was also lower among younger women, as well as among Black (15.5%) and Asian (17.9%) women compared with white women (20.4%).

Godfrey says there is less of a “culture” of taking supplements in certain ethnic groups, and that “accessing care in a way that meets the needs of people from ethnic minorities… is simply not happening”.

Olga Aleksandrova

What’s behind the decline?

For Sehar Shahid, an independent prescriber, founder of 24 HR Pharmacy and board director for Scotland at the National Pharmacy Association, one of the biggest issues is that folic acid tends to be discussed once women are pregnant, rather than before.

As well as many pregnancies being unplanned, she says: “Even when women are actively trying to conceive, they may not have any contact with a healthcare professional until they have a positive pregnancy test.”

Clare Tower, consultant in obstetrics and foetal and maternal medicine at the Manchester University NHS Foundation Trust, agrees that women are not getting advice early enough. “We don’t provide education about pregnancy until people are pregnant,” she explains.

“I think I can count the number of times women have asked me about folic acid in 27 years of practising obstetrics on the fingers of one hand.”

Tower notes that even when women are aware, taking a supplement for what could be many months before conception could be perceived as “cumbersome” by some, and people may forget or lose interest.

Sexual health services may be one setting where that contact does happen and information on folic acid can be given at an earlier stage. Nathan Burley, a sexual health pharmacist at NHS Greater Glasgow and Clyde, says it is a place where preconception care can naturally be raised, particularly with “cohorts we know are having condom-less sex”.

Smoking cessation clinics in community pharmacies may provide a similar opportunity, as they can offer other preconception care, as well as stopping smoking “for better outcomes for both the mother and the child”, he adds.

That contact with healthcare professionals also varies by socioeconomics, with government data showing that 69.6% of women in the least deprived areas attended their first antenatal appointment within 10 weeks of becoming pregnant in 2023/2024, compared with 56.9% in the most deprived.

As already explained, fortification flour may be muddying the message further. Non-wholemeal wheat flour will contain 250mcgs of folic acid per 100g by the end of 2026, which government modelling suggests could cut NTD-affected pregnancies by around 15–22%^​8​.

The Southampton researchers call fortification “potentially the most cost-effective and equitable public health intervention” for preventing NTDs but warn that restricting it to non-wholemeal wheat flour risks “widening health inequalities”.

Godfrey also notes that wholemeal flour is often used to make chapatis in some ethnic communities where supplement intake is already lower. Wholemeal flour is also what the government encourages people to eat because it is healthier^​9​. “It doesn’t make sense,” he says.

Reena Barai, community pharmacist and owner of SG Barai Pharmacy, says that she sees two types of patients in her pharmacy.

“Patients who will take anything and everything because they want to make sure they have the healthiest pregnancy possible and then… patients who are anti-medication, maybe mistrust medication, listening to the wrong influences about whether [vitamins and supplements] are really that important anymore,” she says.

Barai adds: “There is so much health information competing for people’s attention online that a very simple but important public health message can easily get lost.

“Folic acid is inexpensive and widely available, but accessibility doesn’t automatically translate into awareness or uptake.”

Claims circulating online

Aoife Stack, a general dentist with a special interest in orthodontics and orofacial function who treats tongue-tie (i.e. ankyloglossia), told The Pharmaceutical Journal that she’s had parents ask whether folic acid caused their baby’s tongue-tie.

“It’s definitely something parents ask and commonly blame,” she continues. “I think it’s far too simplified to state and I see many babies with ties whose mums did not take folic acid.

“Tongue-tie is likely multifactorial, involving genetic susceptibility alongside nutritional, epigenetic and environmental influences during early embryonic development.”

There is also no evidence that the recommended dose of folic acid is toxic in pregnancy, Stack adds.

The theory may trace back to a 2020 paper proposing that preconception folic acid supplementation could explain rising rates of tongue-tie. A 2023 systemic review found “insufficient evidence” for a link and concluded that the benefits of folic acid outweigh any hypothetical risk. Godfrey, who was part of the team that carried out the review, says there is “no evidence” of a causal link and that misinformation can “undermine people’s trust in something which is safe”.

The claim circulates widely on social media regardless. In one Instagram video, a woman says her midwife told her the rise in tongue-tie is linked to a B vitamin deficiency and that folic acid stops the body absorbing folate.

“That’s why I tell all my pregnant mamas to not have any wheat products, rice or potatoes because they’re enriched or fortified with folic acid,” she quotes the midwife as saying. In the United States — unlike the UK — enriched grain products, such as flour and rice, have been fortified with folic acid since 1998^​10​.

In another video, Barbara O’Neill — described on her website as a “health educator” and banned in 2019 from providing any health services in Australia — tells an audience that pregnant women should not take folic acid because it is “toxic” and “interferes with the fascia”, causing babies to be born with tongue-tie.

Other videos on social media focus on the methylenetetrahydrofolate reductase (MTHFR) gene, which provides instructions for an enzyme that helps convert folate from food into a form the body can use^​11​. Some people carry variants of this gene that can affect how well the enzyme works, with videos and websites circulating that inform these genetic carriers to avoid folic acid.

However, on its website, the U.S. Centers for Disease Control and Prevention says the claim that people with the variant should avoid folic acid is “not true” and that “people with an MTHFR gene variant can process all types of folate, including folic acid”.

Godfrey adds: “There is currently no accepted scientific evidence that folic acid supplementation is deleterious in people with common MTHFR variants; major public health bodies continue to recommend folic acid for women who may become pregnant regardless of MTHFR genotype.”

What can pharmacy teams do?

Guirguis is keen not to place the responsibility solely on women for increasing folic acid uptake. Godfrey agrees. “This is not just about burdening women,” he says. “This is about shared responsibility for pregnancy and parenthood.”

Tower says misinformation on social media “distracts and increases mistrust generally” and that recent negative press about maternity services has added to that. Yet folic acid is cheap, and its benefits go beyond NTDs. “Folic acid deficiency also leads to maternal anaemia which is far more common,” she says. “We see more of this than we do neural tube defects.”

Shahid suspects proactive demand for folic acid in pharmacies is not where it should be but believes community pharmacy is “ideally placed” to change that.

“We already have contact with women through contraception, emergency contraception, fertility and pregnancy testing, medicines, weight management and other services,” she says.

“Pharmacy teams don’t necessarily need another complicated service. They need the tools, training and permission to make every appropriate contact count.”

Barai agrees that training matters, particularly when patients arrive with fixed ideas. She suggests approaches, such as the empathetic refutational interview, which involves asking questions and listening to understand the root of someone’s concerns, before correcting the misconceptions behind them. The technique was originally developed to help healthcare professionals talk to people who are hesitant about vaccines^​12​.

“As pharmacists, we need to learn to exert our own influence… and build trust as trusted healthcare professionals in the community,” she says.

For families affected by NTDs, the stakes are clear. Shine, the charity supporting people living with NTDs and related neurological conditions, told The Pharmaceutical Journal that it is “deeply concerned, but not surprised” by the decline of folic acid uptake. “Fortification is a vital safety net but cannot replace targeted preconception care,” a spokesperson for Shine said.

Pharmacy can reach women outside the traditional maternity pathway by addressing misconceptions and identifying those who need a higher dose, says Guirguis. But timing is crucial and “pharmacy teams can’t solve this on their own”.

For Burley, fortification needs to run alongside better awareness across health services. “A combined approach of mandated fortification of flour plus heightened awareness across the neighbourhood health systems, especially those with links to underserved communities, would be promising,” he says.

Guirguis adds that once fortification begins, its impact must be tracked, “including whether it improves folate status and reduces neural tube defects, and whether the inequalities in uptake and outcomes narrow over time”.