Pregnancy and Postpartum Support
Pregnancy, the period during which a woman’s fertilized egg (embryo) gestates and becomes a fetus, lasts an average of 40 weeks from the date of the last menstrual period to delivery of the infant.
In the first trimester (13 weeks), many pregnant women experience nausea. Usually these women report that they feel best during the second trimester. During the third (final) trimester, the increasing size of the fetus begins to place mechanical strains on the expectant mother, often causing back pain, leg swelling, and other health problems.
Dietary changes that may be helpful for pregnancy and postpartum support
Nearly all pregnant women can benefit from good nutritional habits prior to and during pregnancy. The increased number of birth defects during times of famine attest to the adverse effects of poor nutrition during pregnancy.1 For example, in a dietary survey of pregnant women, higher dietary intake of niacin (a form of vitamin B3) during the first trimester was correlated with higher birth weights, longer length, and larger head circumference (all signs of healthier infants).2
Women who consume a standard Western diet (high in fat and sugar and low in complex carbohydrates) during pregnancy and breast-feeding may not be obtaining adequate amounts of essential vitamins and minerals; this can result in health problems for the newborn.3 Pregnant women should choose a well-balanced and varied diet that includes fresh fruits and vegetables, whole grains, legumes, and fish. Refined sugars, white flour, fried foods, processed foods, and chemical additives should be avoided.
Consumption of moderate to large amounts of caffeine while pregnant has been associated with an increased risk of miscarriage.4 5 6 7 Although some studies suggest that only very large amounts of caffeine increase the risk of miscarriage,8 an analysis of clinical trials found that women who consumed more than 150 mg of caffeine (roughly one to two cups of coffee) per day while pregnant had an increased risk of miscarriage or delivering a baby with a low birth weight.9 The FDA has advised women to avoid drinking coffee and consuming other caffeine-containing foods and beverages during pregnancy.10
Lifestyle changes that may be helpful for pregnancy and postpartum support
A woman can reduce her risk of complications during pregnancy and delivery by avoiding harmful substances, such as alcohol, caffeine, nicotine, recreational drugs, and some prescription or over-the-counter drugs.
Even minimal alcohol consumption during pregnancy can increase the risk of hyperactivity, short attention span, and emotional problems in the child.11 Pregnant women should, therefore, avoid alcohol completely.
Cigarette smoking during pregnancy causes lower birth weights and smaller-sized newborns. The rate of miscarriage in smokers is twice as high as that in nonsmokers,12 and babies born to mothers who smoke have more than twice the risk of dying from sudden infant death syndrome (SIDS).13
Weight Gain in Pregnancy
No single maternal weight gain target meets the needs of all women. The amount of weight a woman optimally gains varies with her height, age, plans to breast feed, and whether she is delivering twins. However, a few basic guidelines are generally accepted:14 Women who enter pregnancy at more than 120% of standard weight still have an obligatory weight gain of 15–25 pounds at a rate of about 0.7 pounds per week. Women who are at ideal body weight and are not going to nurse have a target of gaining about 22 pounds overall at a rate of 0.8 pounds per week. Women who enter pregnancy between 90% and 110% of ideal body weight and plan to nurse have a target weight gain of 25–35 pounds overall at a rate of 0.9 pounds per week during the second and third trimesters. Physically immature adolescents and women less than 90% of ideal body weight have a target weight gain of 32 (28–40) pounds at a rate of 1.1 pounds per week. Women who know they are going to have twins have a target weight gain of 40 (35–45) pounds with a weekly rate of 1.4 pounds during the last 20 weeks of pregnancy.
Another way to determine the appropriate weight gain for pregnancy is by using the Body Mass Index (BMI). The BMI is calculated by dividing your body weight (in kilograms) by the square of your height (in meters). (A kilogram is equal to 2.2 pounds; a meter is equal to about 39 inches.) According to the standard set in 1990 by the Institute of Medicine (IOM) of the National Academy of Sciences,15 a woman with a low BMI (less than 19.8) should gain a total of 12.5–18 kg (27.5–39.7 pounds) during pregnancy; a woman with a normal BMI (19.8–26) should gain a total of 11.5–16 kg (25.4–35.3 pounds) during pregnancy; a woman with a high BMI (greater than 26.0–29.0) should gain a total of 7–11.5 kg (15.4–25.4 pounds) during pregnancy. Adolescents and black women should strive for gains at the upper end of the recommended range. Short women (less than five feet) should strive for gains at the lower end of this range. Obese women (BMI greater than 29) have a separate recommended target weight gain of about 6 kg (13.2 pounds). Published studies suggest that only 30–40% of American women actually have weight gains within the IOM’s recommended ranges.16 17 18
Although the IOM’s national recommendations concerning pregnancy weight gain have been widely adopted, they have not been universally accepted.19 The amount of weight gain during pregnancy varies considerably among women with good pregnancy outcomes.20 21 For that reason, weight gain alone is not likely to be a perfect screening tool for pregnancy complications. Nevertheless, weight gains outside the IOM’s recommended ranges are associated with twice as many poor pregnancy outcomes than are weight gains within the ranges. A systematic review of all studies published between 1990 and 1997 that specifically examined fetal and maternal outcomes showed that weight gain within the IOM’s recommended ranges is associated with the best outcome for both mothers and infants.22
Weight loss programs are not generally recommended during pregnancy. Nevertheless, it should be noted that being overweight while pregnant increases the incidence of various conditions in both the mother and the fetus, such as gestational diabetes and blood pressure problems. The risk is proportional to the amount of excess weight. Overweight women have a higher risk of cesarean deliveries and a higher incidence of anesthetic and post-operative complications in these deliveries. Poor responsiveness in the newborn, large head, and some birth defects are more frequent in infants of obese mothers. Maternal obesity increases the risk of newborn death. The average cost of hospital prenatal and postnatal care is higher for overweight mothers than for normal-weight mothers. Infants of overweight mothers require admission into intensive care units more often than do infants of normal-weight mothers.23
Some women will be concerned that the IOM’s recommended weight gain will result in too much weight gain or more weight retention after the baby is born, but there is no evidence to support this concern. Although there are risks associated with being overweight during pregnancy, dieting during pregnancy can seriously endanger the health of the fetus. A low rate of pregnancy weight gain has been shown, in most studies, to increase the risk of premature delivery.24 There is no evidence that restricting normal weight gain in pregnancy is either safe or beneficial.25
Nutritional supplements that may be helpful for pregnancy and postpartum support
Most doctors, many other healthcare professionals, and the March of Dimes recommend that all women of childbearing age supplement with 400 mcg per day of folic acid. Such supplementation could protect against the formation of neural tube defects (such as spina bifida) during the time between conception and when pregnancy is discovered.
The requirement for the B vitamin folic acid doubles during pregnancy, to 800 mcg per day from all sources.26 Deficiencies of folic acid during pregnancy have been linked to low birth weight27 and to an increased incidence of neural tube defects (e.g., spina bifida) in infants. In one study, women who were at high risk of giving birth to babies with neural tube defects were able to lower their risk by 72% by taking folic acid supplements prior to and during pregnancy.28 Several preliminary studies have shown that a deficiency of folate in the blood may increase the risk of stunted growth of the fetus.29 30 31 32 33 34 35 36 This does not prove, however, that folic acid supplementation results in higher birth weights. Although some trials have found that folic acid and iron, when taken together, have improved birth weights,37 38 39 40 other trials have found supplementation with these nutrients to be ineffective.41 42 43
The relationship between folate status and the risk of miscarriage is also somewhat unclear. In some studies, women who have had habitual miscarriages were found to have elevated levels of homocysteine (a marker of folate deficiency).44 45 46 47 In a preliminary study, 22 women with recurrent miscarriages who had elevated levels of homocysteine were treated with 15 mg per day of folic acid and 750 mg per day of vitamin B6, prior to and throughout their next pregnancy. This treatment reduced homocysteine levels to normal and was associated with 20 successful pregnancies.48 It is not known whether supplementing with these vitamins would help prevent miscarriages in women with normal homocysteine levels. As the amounts of folic acid and vitamin B6 used in this study were extremely large and potentially toxic, this treatment should be used only with the supervision of a doctor.
In other studies, however, folate levels did not correlate with the incidence of habitual miscarriages.49 50 51
Preliminary52 and double-blind53 evidence has shown that women who use a multivitamin-mineral formula containing folic acid beginning three months before becoming pregnant and continuing through the first three months of pregnancy have a significantly lower risk of having babies with neural tube defects (e.g., spina bifida) and other congenital defects.
In addition to achieving significant protection against birth defects, women who take folic acid supplements during pregnancy have been reported to have fewer infections, and to give birth to babies with higher birth weights and better Apgar scores. 54 (An Apgar score is an evaluation of the well-being of a newborn, based on his or her color, crying, muscle tone, and other signs.) However, if a woman waits until after discovering her pregnancy to begin taking folic acid supplements, it will probably be too late to prevent a neural tube defect.
Biotin deficiency may occur in as many as 50% of pregnant women.55 As biotin deficiency in pregnant animals results in birth defects, it seems reasonable to use a prenatal multiple vitamin and mineral formula that contains biotin.
In a preliminary study, pregnant women who used a zinc-containing nutritional supplement in the three months before and after conception had a 36% decreased chance of having a baby with a neural tube defect, and women who had the highest dietary zinc intake (but took no vitamin supplement) had a 30% decreased risk.56
Iron requirements increase during pregnancy, making iron deficiency in pregnancy quite common.57 Iron supplement use in the United States is estimated at 85% during pregnancy, with most women taking supplements three or more times per week for three months.58 Pregnant women with a documented iron deficiency need doctor-supervised treatment. In one study, 65% of women who were not given extra iron developed iron deficiency during pregnancy, compared with none who received an iron supplement.59 However, there is a clear increase in reported side effects with increasing supplement amounts of iron, especially iron sulfate.60 61 Supplementation with large amounts of iron has also been shown to reduce blood levels of zinc.62 Although the significance of that finding is not clear, low blood levels of zinc have been associated with an increased risk of complications in both the mother and fetus.63
Iron supplementation was associated in one study with an increased incidence of birth defects,64 possibly as a result of an iron-induced deficiency of zinc. Although additional research needs to be done, the evidence suggests that women who are supplementing with iron during pregnancy should also take a multivitamin-mineral formula that contains adequate amounts of zinc. To be on the safe side, pregnant women should discuss their supplement program with a doctor.
Supplementation with fish oil (providing either 2.7 g or 6.1 g per day of the omega-3 fatty acids EPA and DHA) significantly reduced recurrence of premature delivery, according to data culled from six clinical trials involving women with a high risk for such complications.65 Fish oil supplementation did not prevent premature delivery of twin pregnancies, nor did it have any preventive effect against intrauterine growth retardation or pregnancy-induced hypertension. Fish oils should be free of contaminants, such as mercury and organochlorine pesticides. Women who eat substantial amounts of certain types of seafood (e.g., swordfish, tuna) may be consuming contaminants that can increase the risk of brain and nervous system abnormalities in their offspring. Exposure to mercury and polychlorinated biphenyls (PCBs) was found to be increased in relation to maternal intake of seafood. Higher exposure to these toxic contaminants has been linked to an increased risk of deficits in the developing brains and nervous systems of the children.66
S-adenosylmethionine (SAMe) supplementation has been shown to aid in the resolution of blocked bile flow (cholestasis), an occasional complication of pregnancy.67 68
Calcium needs double during pregnancy.69 Low dietary intake of this mineral is associated with increased risk of preeclampsia, a potentially dangerous (but preventable) condition characterized by high blood pressure and swelling. Supplementation with calcium may reduce the risk of pre-term delivery, which is often associated with preeclampsia. Calcium may reduce the risk of pregnancy-induced hypertension,70 though these effects are more likely to occur in women who are calcium deficient.71 72 Supplementation with up to 2 grams of calcium per day by pregnant women with low dietary calcium intake has been shown to improve the bone strength of the fetuses.73
Pregnant women should consume 1,500 mg of calcium per day from all sources—food plus supplements. Food sources of calcium include dairy products, dark green leafy vegetables, tofu, sardines (canned with edible bones), salmon (canned with edible bones), peas, and beans.
Are there any side effects or interactions with pregnancy and postpartum support?
Refer to the individual supplement for information about any side effects or interactions.
Herbs that may be helpful for pregnancy and postpartum support
Many tonic herbs, which are believed to strengthen or invigorate organ systems or the entire body, can be taken safely every day during pregnancy. Examples include dandelion leaf and root, red raspberry leaf, and nettle. Dandelion leaf and root are rich sources of vitamins and minerals, including beta-carotene, calcium, potassium, and iron. Dandelion leaf is mildly diuretic (promotes urine flow); it also stimulates bile flow and helps with the common digestive complaints of pregnancy. Dandelion root is traditionally used to strengthen and invigorate the liver.74
Red raspberry leaf is the most frequently mentioned, traditional herbal tonic for general support of pregnancy and breast-feeding. Rich in vitamins and minerals (especially iron), it is traditionally used to strengthen and invigorate the uterus, increase milk flow, and restore the mother’s system after childbirth.75
Nettle leaf is rich in the minerals calcium and iron, is mildly diuretic, and is diuretic. Nettle leaf is rich in the minerals calcium and iron, is and mildly diuretic. Nettle enriches and increases the flow of breast milk and restores the mother’s energy following childbirth.76
In one study, the addition of lavender oil to a bath was more effective than a placebo in relieving perineal pain after childbirth (the perineum is the area between the vulva and the anus.)77 The improvement was not statistically significant, however, so more research is needed to determine whether lavender oil is truly effective.
Numerous herbs, known as galactagogues, are used in traditional herbal medicine systems around the world to promote production of breast milk.78 These are known as galactagogues. Vitex is one of the best recognized herbs in Europe for promoting lactation. An older German clinical trial found that 15 drops of a vitex tincture three times per day could increase the amount of milk produced by mothers with or without pregnancy complications, as compared with mothers given vitamin B1 or nothing.79 However, vitex should not be taken during pregnancy.
Goat’s rue (Galega officinalis) has a history of use in Europe for supporting breast-feeding. Taking 1 teaspoon of goat’s rue tincture per day is considered by some European practitioners to be helpful in increasing milk volume.80 Studies to support the use of goat’s rue as a galactagogue are lacking.
Sage has traditionally been used to dry up milk production when a woman no longer wishes to breast-feed.81 It should not be taken during pregnancy.
Are there any side effects or interactions with pregnancy and postpartum support?
Refer to the individual herb for information about any side effects or interactions.
Holistic approaches that may be helpful for pregnancy and postpartum support
In one preliminary study, acupuncture relieved pain and diminished disability in the low back during pregnancy better than physiotherapy.82
A controlled trial found that acupuncture significantly reduced symptoms in women with hyperemesis gravidarum, a severe form of nausea and vomiting of pregnancy that usually requires hospitalization.83 Treatment consisted of acupuncture at a single point on the forearm three times daily for two consecutive days. Acupressure (in which pressure, rather than needles, is used to stimulate acupuncture points) has also been found in several preliminary trials to be mildly effective in the treatment of nausea and vomiting of pregnancy.84 85 85