[:vi]We took into account heterogeneities across registries by using random effects models. Nevertheless, we cannot exclude the possibility that registration problems or other data artefacts may be a partial explanation of the observed trends (or lack thereof) in the prevalence of NTD. However, we had no a priori reason to believe that any changes in registrations would have occurred in specific periods of time in a way that would explain the observed, long term time trends in our study.Comparisons with other studiesOur results are consistent with those of an older study of trends in the prevalence of NTD in Europe.10 The overall long term fluctuations in the total prevalence of NTD in our data cannot be due to mandatory fortification of food staples, as such a policy has not yet been implemented in European countries.9 Voluntary fortification or the various recommendations issued for folic acid supplementation for women of reproductive age in European countries may have had an effect,9 18 19 even if small and as yet very little documented, on the intake of folic acid and thereby the prevalence of NTD.9 12 18 However, the available evidence points to very low uptake of folic acid supplementation in European countries.11 12.
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