It has been proposed by the National Council on Folic Acid, a collaboration of over 80 organizations dedicated to women's and infants' health, that oral contraceptive pills (OCPs) be fortified with folic acid. I agree with this position. Neural tube defects (NTDs) are the second most common serious birth defect in the United States, with approximately 1 in 1,000 live births affected. We know that consumption of folic acid in the periconceptional period can reduce the incidence of NTDs by 50% to 70% (Centers for Disease Control and Prevention [CDC], 2004), but the folic acid story doesn't end there. In addition to providing protection to a developing fetus, folic acid may reduce the risk of heart disease and certain kinds of cancer in women; therefore, both the Institute of Medicine and the U.S. Public Health Service recommend that every woman of childbearing age consume 0.4 mg of synthetic folic acid daily in addition to a diet rich in natural folates (CDC, 2004).

While general awareness about the importance of taking folic acid has increased markedly, subsequent behavior change continues to be slow to follow. With only about 27% of women taking a daily vitamin (CDC, 2004), there is still a glaring need for more attention to this issue. Many campaigns begun to increase folic acid consumption have focused first on women contemplating pregnancy and later on women who are noncontemplators. The first group has tended to be easier to reach and more receptive to the message. The second has been much more challenging. With over 50% of pregnancies unplanned, there remains a large group of women who are not contemplating pregnancy and yet are at risk (Henshaw, 1998). How can we reach these women?

If OCPs contained folic acid, they could provide the recommended 0.4 mg of folic acid daily to the approximately 17 million women in the United States who use this form of birth control. Even if these women took their OCP along with a daily multivitamin containing folic acid, we would not need to be concerned about overdose of folic acid, because even 1 g of folic acid is not considered an overdose (Institute of Medicine, 1998).

Combining folic acid and OCPs would afford NTD protection to the unplanned pregnancies occurring among OCP users each year. Because women who are taking OCPs do not expect to become pregnant while on them, they are likely among the women who are not presently taking folic acid daily, the target group we are trying to reach. Continuous use of such a product could increase serum folate levels and afford some level of protection against an NTD-affected pregnancy. Of course, when women decide to stop taking OCPs and to become pregnant, their healthcare providers would have a responsibility to counsel them about folic acid supplementation. The potential for an added few months of protection for a new contemplator of pregnancy may have an important impact on the prevention of NTDs.

Adding folic acid to OCPs has the potential to increase opportunities to educate providers about folic acid as well as increase the likelihood that they will talk with their patients about folic acid. Additionally, women would be exposed to messages about folic acid on the product packaging and possibly from pharmacists as well. Remembering to take a pill every day is a barrier often expressed by women in folic acid campaign focus groups. If the millions of women who are in the habit of taking a pill every day in the form of OCPs could get their folic acid in this way, it could have a major impact on the consumption of this important vitamin.

The National Council on Folic Acid suggests that OCP fortification with folic acid should be done immediately and should be considered one more tool in the arsenal of efforts to promote daily vitamin use. National and state folic acid campaigns should continue with their same vigor and commitment. These campaigns must continue to be creative and target young women with messages about the multiple benefits of daily folic acid consumption.

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