Background:
Daily use of supplements containing at least 400 micrograms of folic acid before and during pregnancy reduces the risk of neural tube defects (NTDs). Although all women capable of becoming pregnant are recommended to consume folic acid regularly, the majority do not do so.

Objectives:
This presentation presents economic evaluations of two different types of folic acid interventions aimed at women prior to conception both of which have been proven effective in reducing the number of infants born with an NTD. One is a program in South Carolina which targets women with a previous NTD-affected pregnancy identified through a birth defects surveillance system to counsel them and provide vitamin supplements. The other program provides counseling and vitamin supplements to sexually active lower-income women attending public family planning or health clinics in Kentucky.

Methods:
The analyses calculate intervention costs, numbers of NTDs averted, gains in quality-adjusted life-years (QALYs), and averted costs of care resulting from the prevention of NTDs. The estimated lifetime direct cost of spina bifida ($570,000 in 2003 dollars) incorporates new estimates of medical expenditures for adults with spina bifida and lost earnings of parental caregivers.

Results:
Both programs appear cost-effective in comparison with other health care interventions, with cost-effectiveness ratios less than $50,000 per QALY.

Conclusion and implications for practice:
From a societal or public health perspective, targeted folic acid supplementation and counseling programs can provide good value for money. Whether financial returns to specific payers are as attractive is less clear, because individual payers do not capture the benefits of reduced medical costs over a lifetime. Similarly, the increased economic productivity of parents, mostly mothers, resulting from primary prevention of child disability is included in the societal calculations of net benefit but not in the return on investment for a healthcare payer.