Level 2: Mid-level evidence
A program of mandatory folic-acid fortification of flour and pasta products was instituted in Quebec in 1998. A recent study compared the rates of birth defects before and after the start of the program in 1,324,440 births from 1990-2005 (BMJ. 2009;338:b1673). Birth prevalence of severe congenital heart defects (including tetralogy of Fallot, endocardial cushion defects, univentricular hearts, truncus arteriosus, or transposition complexes) fell from 1.64 per 1,000 births before fortification to 1.47 per 1,000 births after fortification. Over the seven years since the introduction of fortified grain products, birth prevalence of heart defects decreased by 6% per year.