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If you’re pregnant or thinking about getting pregnant, preparing your body for a healthy pregnancy and nourishing your growing baby are probably on your mind. Along with eating as well as you can to optimize your fertility and pregnancy health, this is the time many women consider whether or not they should be taking a prenatal vitamin and which one of the many options to choose. In fact, one of the most common questions I get is: do I need a prenatal vitamin? And if so, how do I know if I’m getting a good quality one?
I’d love to share how prenatal vitamins may help you to optimize preconception and pregnancy and what exactly I recommend to the women I work with. Let’s clear the confusion so you can feel confident in the choice you make for your health and baby’s health.
Do You Need to Take a Prenatal Vitamin?
I do recommend all women in childbearing years take a prenatal vitamin. While ideally we’d be getting all of the nutrients we need from our diet, and perhaps you are, between modern agriculture, depleted soil, our busy lives, medications (including the birth control pill) which deplete us of important nutrients, and symptoms like prenatal nausea that can limit our intake, unfortunately most women are just not getting all we need from our diets. Major studies show that women of childbearing age – including most women in the US- are chronically low in numerous nutrients –including vitamin B6, vitamin E, vitamin D, folate/folic acid, essential fatty acids, iron, iodine, calcium, zinc, and magnesium — that are critical for optimal wellbeing of mom and baby from conception through pregnancy – and even postpartum. Many women are going into pregnancy already nutrient depleted and then added to this are the naturally increased nutrient needs of pregnancy and breastfeeding.
Of course, food should always be our first source of nutrition. Eating a healthy, varied diet in pregnancy will help you get most of the vitamins and minerals you need. Prenatal vitamins do not take the place of a healthy diet in creating a strong nutrition foundation for you and baby, but they an extra insurance policy to help bridge the gaps in what’s missing. Read this article to learn more about what to eat for fertility and pregnancy.
The Impact of Prenatal Vitamins
Numerous studies show that taking a prenatal vitamin not only improves baby's health, but also the health of the mom. Benefits include improved likelihood of becoming pregnant and reduced the risk of miscarriage, prenatal anxiety and depression, and postpartum depression – which can have a tremendous impact on the experience of being a mom. There is also reduced risk of pregnancy complications including gestational hypertension, preeclampsia, preterm birth, low birth weight babies, birth defects, and stillbirth – all of which can have massive health and safety consequences for mom and baby, including complications associated with prematurity and long hospital stays, and a possible reduction in risk of autism. We also see lower rates of long-term chronic problems that can affect our children later in life, for example, diabetes, and cardiovascular disease, when preconception nutrition is optimized.
Starting and Continuing Prenatal Vitamins: When and for How Long?
The reality is that half of the pregnancies in the US are unplanned, meaning that many women don’t have the opportunity to optimize preconception nutrition intentionally before realizing they are pregnant. So I suggest all women in their childbearing years who are sexually active take a prenatal at best, but at least 800 mcg/day of methylfolate and 2000 units of Vitamin D (see below). This is particularly important because one nutrient, folic acid, is essential for the healthy development of the baby’s nervous system which largely takes place before most women even realize they’re pregnant!
Taking a prenatal vitamin can give you some assurance in case you do become pregnant – whether intentionally or unexpectedly, and it also buffers you from nutrient depletions you may have but be unaware of. It becomes especially important when you start thinking about becoming pregnant as part of a healthy preconception plan, which will not only optimize your health when your pregnant, but also optimizes conception and fertility. If possible, I recommend starting 3-6 months in advance. If you don’t have that opportunity, begin as soon as you know you’ve conceived. After baby is born, I recommend remaining on your prenatal vitamin for at least 3 months, and if you are breastfeeding, at least 12 months, including for a few months after you’ve weaned to replenish your nutrients – and if you plan to become pregnant again – just stay on the prenatal vitamin as a daily nutrient supplement. However, not all prenatal vitamins are created equally – and it’s not simply a prenatal vitamin that we need – there’s an array of nutrients that truly support optimal nutrition for you and baby.
Are All Prenatal Vitamins Created Equal?
Too often I hear that while women are recommended to take a prenatal vitamin at their initial prenatal visit, most are told that it doesn’t matter which they choose – that all provide what they need. In medical school we were taught to even just recommend “Flintstones chewables’ to mom with prenatal nausea to make them easy and palatable to take. While it is actually still better to get any prenatal vitamin over none, unfortunately, many prenatal vitamins fall short of meeting women’s preconception and prenatal needs. Not to mention that many are loaded with all sorts of additives, fillers, and artificial colors. When evaluating the quality of prenatal vitamins, I look at both the levels of key nutrients they provide against standards for what we know is optimal for pregnant women to receive, as well as the form they are in – since both influence how well the body is able to use and absorb that nutrient – in other words – their bioavailability.
It’s also important to recognize that while nutrient levels may meet the Percent Daily Value listed on the label, it doesn’t mean that this amount is actually optimal; rather it’s simply the percent of that nutrient that meets the expected average daily intake need for any healthy adult – not specific to women, let alone pregnancy needs. Optimal standards do exist; one just has to dig a little into the medical literature to find them -something I’ve been doing – and teaching midwives and physicians for two decades now.
Here are the nutrients I look for when evaluating prenatal vitamin quality – and why:
- Methylfolate: In this article I talk about the importance of methylation and the MTHFR gene for pregnancy health. During pregnancy folate plays a special role in the formation of baby’s chromosomes and nervous system, as well as mom’s health. Adequate levels improve egg quality and prevent miscarriage as well as other pregnancy complications including preclampsia and placental abruption. It prevents neural tube and other defects in baby and may protect against autism. For these benefits, it needs to be taken in the first 28 days of pregnancy. It also protects against prenatal and postpartum depression in mom. However, if you have the MTHFR gene, you can’t make full use of what you’re getting from your diet or the regular folic acid found in most vitamins. That’s why I put all women who are pregnant or planning to conceive on methylfolate, which everyone can metabolize. Your prenatal should contain 400 to 800 mcg methylfolate.
- Vitamin B6:Supports healthy levels of progesterone which creates a healthy uterine lining for implantation. Many women enter pregnancy low in B6, especially if they’ve been using hormonal contraceptives. It’s best to take the active form, Pyridoxal-5-phosphate (P5P), in a range of 5-10 mg per day. Going into pregnancy with adequate B6 levels may also prevent morning sickness (it can be supplemented at 50-100 mcg/day if you do get this common pregnancy symptom).
- Iron:Low iron and anemia is associated with many adverse maternal and fetal outcomes. Anemia can lead to reduced maternal immunity which increases infection rates and is associated with intrauterine infection. Iron supplementation leads to longer gestation and improved birth weight. A prenatal vitamin that iron also reduces ovulatory infertility. Your prenatal should contain 27 mg of ideally iron chelate, which is a non-constipating form.
- Iodine: Critical to your healthy thyroid function and therefore healthy menstrual cycles and fertility, as well as prevention of miscarriage and stillbirth. Once pregnant, it's also critical to your baby’s thyroid, brain development, and central nervous system development. Even mild iodine insufficiency can affect your thyroid health and fertility, and deficiency is associated with reduced IQ and cognitive development in baby. Your prenatal vitamin should contain a daily dose of 200 to 250 mcg of iodine. It’s important to note, however, that excess intake can cause thyroid suppressing in the baby, so if you’re taking an iodine supplement that exceeds the recommended amount (i.e., for natural thyroid treatment or breast health), decrease to the recommended dose once you start trying to conceive.
- Choline:Essential for baby’s neurologic development and signaling, and cognitive function, especially memory, focus, and attention. Adequate intake may prevent birth defects and provides your child with stress resilience and protection from anxiety. While it can be obtained from the diet, many women’s diets fall short, especially if you don’t eat egg which is one of the primary sources aside from beef and calf liver (which I don’t recommend for any woman during preconception or pregnancy due to the high level of contaminants in organ means). Your prenatal should contain: 400 mg.
- Zinc: Plays a role in ovulation, supports healthy estrogen and progesterone levels, and is important for optimal immune function. It protects the developing egg against oxidative damage, supports healthy oocyte development, and is important for fetal brain development and function. Your prenatal should contain between 15- 45 mg zinc daily.
Additional Nutritional Needs
While a good quality prenatal vitamin covers most of what you need, there are a few additional nutrients that I recommend supplementing with since they are either not found in prenatal vitamins or if they are, the amounts are too low to truly meet your prenatal needs:
- Omega-3 Fatty Acids: Play an essential role in conception, and the formation and development of the oocyte and embryo. Higher intake is associated with better ovarian reserve and higher rates of conception. Your intake of DHA prenatally is also critical for baby’s brain and neurological development, may prevent preterm labor, regardless of other risk factors. Interestingly, a couple of studies have shown that it can improve stress resilience, including to even severe social stressors, while EPA can prevent prenatal and postpartum depression. I recommend a combined DHA/EPA, either from fish oil or a vegan source.
- Vitamin D: Plays a strong role in sex hormone production and is associated with improving fertility. It can reduce insulin resistance in women with PCOS and plays a role in preventing and treating fibroids and endometriosis. It promotes healthy follicle formation, and in studies of women undergoing IVF, women with higher vitamin D levels have not only pregnancy rates 35% higher, but higher quality embryos compared to those who are deficient. It also appears to prevent preterm labor. Food sources include fatty fish, eggs, and cod-liver oil. Sunshine is also an important source, but dietary sources and sunshine aren’t usually enough to meet fertility and pregnancy needs. Dose: the amounts in a prenatal vitamin are typically lower than needed, so a separate supplement is needed. For most women, 2000 iu daily will take care of deficiency, but it’s ideal to have your level checked and supplement accordingly, as women with a serum vitamin D level > 30 ng/mL have the greatest chances of getting pregnant.
- A probiotic: Taking a probiotic may augment fertility, conception (including with IVF), and healthy pregnancy in a variety of ways. Disruption in the vaginal microbiome can favor the growth of organisms that interfere with fertility and increase pregnancy risk including miscarriage and preterm birth. Women undergoing IVF often have higher levels of BV and abnormal vaginal flora, which is now suspected to be a cause of the infertility that led them to treatment and may also interfere with IVF success. Probiotics can also help reduce inflammation and regulate blood sugar. Taking a probiotic containing a broad spectrum of Lactobacillus species may provide you with a fertility advantage and taking Lactobacillus rhamnosus during pregnancy can also help prevent urinary tract infections, gestational diabetes, preeclampsia, as well as prenatal and postpartum anxiety and depression. Women who take a probiotic through the third trimester may help to prevent eczema, allergies, and asthma in their babies.
My Review of Prenatal Vitamins
So many women ask me what prenatal I recommend, and I get it – between the numerous options and lack of guidance – it’s confusing – and really overwhelming. And who wants to pay top dollar for supplements if they’re still inadequate in certain nutrients, and so many are. While I typically don’t recommend specific products, this is an area where I feel it’s important to some guidelines that help you to make the best decision, and highlight these in action in the form of products that do appear to be high quality.
Toward this, my team (consisting of a licensed nutritionist and a registered dietician) and I did a deep dive into the most popular prenatal vitamin products on the market – both those typically recommended by physicians (i.e., medical grade) and over the counter – to identify the best options we feel good about recommending. We evaluated not only the nutrients, but also the sourcing of ingredients, the presence of additives or fillers, as well as the company’s testing standards and ethos surrounding their environmental impact. Unfortunately, prenatal vitamins, like many other supplements, are not adequately regulated evaluated by the FDA for quality or that they actually contain the levels of nutrients they claim. What makes this even more worrisome is that some have been found to be contaminated with heavy metals like lead – to learn more about heavy metals and pregnancy, read Should I Detox Before Getting Pregnant. This is why it was so important that we evaluate products based on their testing standards, including heavy metal analysis, and for additives and fillers – especially at a time when you’re trying your best to reduce environmental exposures.
While not all of these options meet the exact amounts I specify above, only those that come very close and meet our ethical and environmental standards made the list. Unfortunately, when evaluating other over the counter products, and those typically recommended by physicians, none came close to the recommended levels of nutrients that seem to be the most important.
I understand that some of these options may be cost prohibitive and I hope to help offset this through The Replenish Formulary, where you will find some of the products mentioned above (noted by a *) available at a 20% discount. When looking at the price point – and yes – these are expensive compared to conventional brands — which is why I emphasize that the studies show any prenatal is better than none – also look to what’s included as some are all-in-one prenatal nutrition packets that include not only a prenatal vitamin itself, but also essential fatty acids, vitamin D, and possibly a probiotic.
This is also not an exhaustive list – there are many other companies out there – and in fact, right now prenatal supplement companies are a really hot investment pathway flowing with venture capital – so we’re bound to see more companies popping up. And there may be some companies that have a good prenatal product, but which are produced by companies that don't have the ethos we prefer to support, for example one product with good quality ingredients and nutrient levels, but is owned by a major multi-national consumer goods and pharmaceutical corporation which produces products with a harmful environmental impact.
You can trust that we will stay current with market research in case there is new information that sheds a different light on any of the products shared here – especially since some are new to the marketplace. Please know that I have no financial arrangements with any prenatal supplement company, nor any financial arrangements of any kind with any of the companies reviewed in this chart.
Choosing What’s Best for You
Once we know the quality is there, the decision of which to take becomes a matter of your personal preference and tolerance – dose, cost, form, and a little bit of trial and error to find what works all come into play. What one woman loves, another may get nauseated at the smell of – which is why knowing about several available options and different forms, i.e., traditional tablet, gummy, powder, and how many you have to take daily — is important. And if you have trouble taking a prenatal, you’re not alone. Prenatal vitamins were the thing that made me the most nauseated when I was pregnant – I for example, would have loved a gummy option – but they didn’t exist at that time.
Here are the tips I’ve found work best for tolerating prenatal supplements when you’re pregnant – and especially if you’re having ‘morning sickness:’
- Always take your prenatal supplements with food and avoid taking it on an empty stomach.
- Try taking them in the late morning or at lunch, and late afternoon instead of early in the day. I find that taking it in the morning can make women nauseous because their stomach acid hasn’t quite gotten revved up yet while taking them in the evening may cause heartburn for some
- Take your prenatal supplements with something that's slightly acidic, like a small glass of lemon water or grapefruit juice.
- If you can’t tolerate pills, try a gummy version like Smarty Pants or a powdered form added to a smoothie like the Needed Prenatal Multi above.
As a mom, I know there is little more important than the health of your family. While the topic of prenatal vitamins has become a confusing and overwhelming at times, it should be a simple but impactful step in your preconception and pregnancy journey. You deserve to feel empowered in the choices you make, knowing you are providing the best nourishment for your health and the health of your baby – and I hope this guidance here helps do just that.