Maternal Dietary Diversity and Neural Tube Defect Prevention: A Policy Analysis for the Eastern Cape, South Africa

**Abstract** Neural tube defects (NTDs) represent a persistent public health challenge in South Africa, with prevalence in the Eastern Cape province remaining notably high. Although periconceptional folic acid supplementation is a proven preventive measure, maternal dietary diversity—a key indicator of nutritional quality and micronutrient sufficiency—is an underexplored modifiable factor in resource-limited settings. This study aimed to synthesise evidence on the association between maternal dietary diversity and NTD risk, and to critically review relevant South African policies to formulate integrated recommendations. A systematic policy analysis was undertaken, comprising a narrative synthesis of epidemiological literature from analogous African settings and a structured review of national nutritional and antenatal care policies using a health policy analysis framework. The findings indicate a consistent inverse relationship between greater periconceptional dietary diversity and reduced NTD risk, underscoring the importance of a spectrum of micronutrients, including vitamin B12 and zinc. The policy review revealed a predominant focus on single-nutrient supplementation, with minimal integration of holistic dietary guidance within maternal health services. This analysis concludes that strengthening dietary diversity is a crucial complementary strategy to folic acid interventions for NTD prevention. Recommendations include revising antenatal care protocols to incorporate dietary diversity assessment and counselling, utilising simple metrics for monitoring, and implementing community-based nutrition education programmes promoting locally available, nutrient-rich foods to bridge the identified policy-practice gap. **Keywords:** neural tube defects, dietary diversity, maternal nutrition, policy analysis, South Africa, periconceptional period