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By Dr. Homero Martinez
Senior Technical Advisor, Large-Scale Food Fortification, Research & Development Unit, Nutrition International
Ethiopia is taking a groundbreaking step to prevent one of the country’s most common and preventable causes of birth defects and child deaths. Approximately 60% of women of reproductive age (18-49 years) have insufficient folate, putting thousands of pregnancies at risk for neural tube defects (NTDs) — serious birth defects that occur when the closure of a baby’s brain or spinal cord does not develop properly. NTDs, such as spina bifida and anencephaly, can result in lifelong disability, or in severe cases, early death. In Ethiopia, nearly half of NTD-affected pregnancies result in stillbirth or neonatal death, while children who survive often require complex medical care and lifelong support. These defects occur very early in pregnancy, often before a woman even knows she’s pregnant, making prevention through adequate folic acid intake essential.
Until now, preventing NTDs in Ethiopia has been challenging. In other countries, folic acid fortification has largely been limited to wheat flour, which is not widely consumed by the Ethiopian population. This leaves millions of women without the folate they need during their most critical reproductive years, particularly in rural and low-income settings where industrialized wheat consumption is lower. Given the scale of folate insufficiency and the toll NTDs take on families, communities and the national health system, an accessible, population-wide solution has been urgently needed.
Building on decades of research and innovation, Ethiopia is now poised to become the first country in the world to introduce double-fortified salt with iodine and folic acid (DFS-IoFA) at national scale. Developed more than 20 years ago in Canada, DFS-IoFA is a safe, practical and highly effective solution to improve folate status and dramatically reduce the risk of NTDs across the country. Salt is one of the few foods consumed in consistent amounts by nearly all households, regardless of income or location, making it an especially effective vehicle for delivering essential nutrients at scale and reaching women before and during early pregnancy, when folate is most critical. By combining folic acid with the already widely consumed iodized salt, the intervention ensures broad and equitable coverage without requiring additional behaviour change or supplementation programs.
A recent peer-reviewed, community-based, household-randomized trial published in The American Journal of Clinical Nutrition included 360 non-pregnant Ethiopian women aged 18-49, conducted by Nutrition International in collaboration with the Ethiopian Public Health Institute and UC Davis, confirmed the biological effect of DFS-IoFA. Over 26 weeks, participants received iodized salt fortified with varying doses of folic acid, and the study found that DFS-IoFA safely and effectively improved folate levels without detriment of iodine status. The results suggest that fortifying all discretionary iodized salt with the recommended dose of folic acid could reduce folate insufficiency among women of reproductive age from 60% to just 10%, representing a major leap forward for public health in Ethiopia. Scaling this intervention nationally could prevent thousands of NTD-affected births each year, reduce health system costs, alleviate the need for specialized lifelong care, avoid the burden on families of having to care for an affected child, and increase productivity by helping children reach their full potential.
Beyond its health impact, this approach positions Ethiopia as a regional leader in salt fortification. By building on existing iodization infrastructure and making minimal technical upgrades, the country can stimulate local investment in folic acid premix, create opportunities for production and export, and serve as a model for other nations facing similar challenges. The Government of Ethiopia and its partners have demonstrated strong commitment to this initiative, underscoring the critical role of national leadership in translating research into real-world impact.
Nutrition International continues to support Ethiopia’s transition from research to national scale-up, working alongside government and partners to ensure that DFS-IoFA reaches every household. The initiative demonstrates how Canadian innovation, local expertise and international collaboration can come together to transform research into real-world health benefits for millions.
As Ethiopia prepares to expand DFS-IoFA nationally, the intervention represents more than just a scientific achievement. It is a transformative public health strategy capable of saving lives, preventing lifelong disability, and easing the social and economic burdens associated with NTDs. With the potential to reach virtually every household, DFS-IoFA stands as a landmark example of how evidence-based interventions backed by political will and building up on technical innovation, can deliver lasting health benefits at scale. Ethiopia is not only safeguarding the health of its next generation — it is setting a precedent for the world.
Editor’s Note : Views in the article do not necessarily reflect the views of borkena.com
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