Pregnancy Care Guidelines

11 Nutrition and physical activity

Consuming a wide variety of nutritious foods during pregnancy is important to ensure that the nutritional requirements of both mother and baby are met.

Consuming a wide variety of nutritious foods during pregnancy is important to ensure that the nutritional requirements of both mother and baby are met. While supplementation of vitamins and minerals is common during pregnancy, only some supplements are beneficial. Regular physical activity has health benefits for mother and baby and is safe.

11.1 Nutrition

The nutritional status of a woman before and during pregnancy plays a vital role in fetal growth and development. The basic principles of healthy eating remain the same, though requirements for some nutrients (eg iron, folic acid) may increase.

11.1.1 Background

Knowledge about healthy eating during pregnancy

Observational studies carried out in Australia have found:

  • low levels of awareness of dietary guidelines during pregnancy among women (Bookari et al 2016); (Lee et al 2016)
  • low levels of women meeting dietary recommendations for the five food groups (Mishra et al 2015); (Malek et al 2016b); (Bookari et al 2017); (Lee et al 2018a)
  • low levels of knowledge of foods to avoid during pregnancy (Bryant et al 2017)
  • limited dietary counselling by health professionals (Lee et al 2016); (Lee et al 2018b).

An Irish cohort study (McGowan & McAuliffe 2013) found that women with a 'health conscious' dietary pattern were older, had a higher level of education and had a lower BMI than those with an 'unhealthy' dietary pattern. A study in New Zealand also found that a ‘health conscious’ dietary pattern was associated with increasing age, better self-rated health, lower pre-pregnancy BMI and not smoking (Wall et al 2016).

    Access to healthy food

    • Geographical location: The decreased availability and affordability of nutritious foods (such as fresh fruit and vegetables and wholegrain bread), especially in remote and regional areas in Australia has been described frequently. The cost of nutritious foods in these areas can be over 30% higher than in major cities and may affect food purchases (NHMRC 2000)(NT DHCS 2007)(Harrison et al 2010); (Landrigan & Pollard 2011).
    • Socioeconomic status: In some urban centres, people in lower socioeconomic groups have less access to supermarkets and greater access to fast food outlets than more advantaged groups (Burns & Inglis 2007), (Ball et al 2009). Supermarkets generally offer a wider variety of food products, as well as fresh raw food.
    • Migrant and refugee women: Following migration, food habits may change out of choice, because of the limited availability of traditional and familiar foods, or because of change in economic circumstances in Australia. Similarly, financial and language difficulties may affect access to education and employment opportunities which then affects income, health and nutrition literacy, and access to nutritious foods. Some migrants experience disadvantages such as social isolation and poor housing, which can affect access to safe food and safe preparation of food, and are generally in a relatively vulnerable position in their new environments, regardless of the type of migration (WHO 2010).

    11.1.2 Discussing nutrition

    Australian dietary guidelines for pregnant women

    As outlined in the Australian Dietary Guidelines (NHMRC 2013), consuming a variety of nutritious foods is particularly important during pregnancy and breastfeeding.

    • Vegetables, legumes/beans and fruit: consumption of vegetables and fruit before and during pregnancy make important contributions to health outcomes for women and their children.
    • Grain (cereal) foods: wholegrain foods are a valuable source of iron and zinc and fibre. Most bread in Australia is fortified with folic acid and made with iodised salt.
    • Lean meats and poultry, fish, eggs, tofu, nuts and seeds, and legumes/beans: lean red meat and chicken are good sources of protein, iron and zinc. Maternal consumption of fish during pregnancy is likely to have a range of health benefits for women and their children but the fish should be low in mercury (see Table C2). Nuts, seeds and legumes/beans are important foods for people who choose vegetarian or vegan dietary patterns and meals without meat, as they can provide an alternative source of nutrients. For several nutrients, including iron, calcium and vitamin B12, care needs to be taken to include a variety of alternatives if animal foods are excluded.
    • Milk, yoghurt and cheese and/or their alternatives: milk, yoghurt and cheese or their alternatives are good sources of calcium.
    • Water: pregnant women require more water to support fetal circulation, amniotic fluid and a higher blood volume — fluid need is 750–1,000 mL a day above the estimated daily intake of 2.1 L.
    • Foods containing saturated fat, added salt, added sugars: intake of these foods should be limited in general and during pregnancy. The additional energy requirements of pregnancy should be met through additional serves of foods from the five food groups rather than energy-dense foods.
    • Alcohol: not drinking alcohol is the safest option during pregnancy (see Chapter 13).

    Table C1 outlines the recommended number of serves of different food groups during pregnancy. However, it is acknowledged that dietary patterns may vary depending on cultural background. 

    Table C1: Recommended number of daily serves for women who are pregnant or breastfeeding

    Food group Sample serve Pregnancy Breastfeeding
        <19 yrs 19–50 yrs <19 yrs 19–50 yrs
    Vegetables of different types and colours, and legumes/ beans

    ½ cup cooked green or orange vegetables; ½ cup legumes;  
    1 cup raw green leafy vegetables; ½ medium potato (or sweet potato, taro or cassava); ½ cup sweet corn; 1 medium tomato 

    5 5 5.5 7.5
    Fruit 1 medium apple, banana, orange or pear; 2 small apricots, kiwi fruits or plums; 1 cup diced or canned fruit (no sugar), 30 g dried fruit (only occasionally)  2 2 2 2
    Grain (cereal) foods, mostly wholegrain and/or high cereal fibre varieties, such as breads, cereals, rice, pasta, noodles, polenta, couscous, oats, quinoa and barley 1 slice bread; ½ medium roll or flat bread; ½ cup cooked rice, pasta, noodles, polenta or quinoa; ½ cup porridge; 2/3 cup wheat cereal flakes; ¼ cup muesli; 3 crispbreads  8 8.5 9 9
    Lean meats and poultry, fish, eggs, tofu, nuts* and seeds, and legumes/beans  65 g cooked lean red meat; 80 g cooked chicken; 100 g cooked fish fillet; 2 large eggs; 1 cup cooked lentils or canned beans; 170 g tofu; 30 g nuts, seeds, peanut or almond butter or tahini  3.5 3.5 2.5 2.5
    Milk, yoghurt, cheese and/or their alternatives (mostly reduced fat) 1 cup milk; 200 g yoghurt;  
    40 g hard cheese; ½ cup ricotta cheese; 1 cup soy, rice or other cereal drink with added calcium 
    3.5 2.5 4 2.5
    Approximate number of additional serves from the five food groups or discretionary choices 0–3 0–2.5 0–3 0–2.5
    • * Note that nuts need only be avoided if the woman has an allergy to them. 
    • Source: (NHMRC 2013).

    Table C2: Foods to be consumed with caution during pregnancy

    • Due to the risk of listeriosis, pre-prepared or pre-packaged cut fruit or vegetables should be cooked. Pre-prepared salad vegetables (eg from salad bars, including fruit salads and cut melon) should be avoided 

    • Raw or undercooked meat, chilled pre-cooked meats, and pâté and meat spreads should be avoided during pregnancy due to risk of listeriosis 

    • Care needs to be taken with consumption of some fish species (eg shark/flake, marlin or broadbill/swordfish, orange roughy and catfish) due to the potentially higher mercury content 

    • Foods containing raw eggs should be avoided due to the risk of salmonella 

    • Unpasteurised dairy products and soft, semi-soft and surface-ripened cheese should be avoided due to the risk of listeriosis 

    • Sugar-sweetened drinks are associated with dental conditions, such as caries 

    • Food Standards Australia and New Zealand suggests limiting intake during pregnancy to 200 mg/day of caffeine (FSANZ 2019), noting that caffeine is present in coffee (145 mg/50 mL espresso; 80 mg/250 mL instant coffee), tea (50 mg/220 mL), colas (36 mg/375 mL), energy drinks (80 mg/250 mL) and chocolate (10 mg/50g). 

    Source: (NHMRC 2013); (FSANZ 2019)

    Recent evidence on dietary patterns 

    Dietary patterns associated with healthy outcomes generally have high intake of fruits, vegetables, legumes, wholegrains, fish, seafood, lean meats, low-fat dairy and water. Dietary patterns associated with poorer outcomes include those high in sweetened foods and beverages, foods high in saturated fats (eg fried foods), red and processed meats and refined grains.  

    A healthy dietary pattern can help reduce the risk of: 

    • excessive gestational weight gain (Ramson et al 2020)

    • gestational diabetes (Martin et al 2016); (Schoenaker et al 2016); (Assaf-Balut et al 2017); (Zareei et al 2018); (Pham et al 2019) 

    • gestational hypertension (Schoenaker et al 2014); (Gresham et al 2016); (Ikem et al 2019)

    • antenatal depression (Miyake et al 2018)

    Conversely, an unhealthy dietary pattern may increase the risk of gestational diabetes (Shin et al 2015); (Flynn et al 2016) and antenatal depression (Baskin et al 2017)

    The evidence is inconsistent on the association between dietary pattern in pregnancy and: 

    • preterm birth (Englund-Ogge et al 2014); (Rasmussen et al 2014); (Saunders et al 2014); (Smith et al 2015); (Assaf-Balut et al 2017); (Assaf-Balut et al 2018); (Chia et al 2018); (Chia et al 2019); (Raghavan et al 2019))

    • fetal growth (Martin et al 2015); (Flynn et al 2016); (Gresham et al 2016); (Assaf-Balut et al 2017); (Chia et al 2018); (Emond et al 2018); (Martínez-Galiano et al 2018); (Assaf-Balut et al 2019); (Chia et al 2019); (Englund-Ogge et al 2019) 

    • childhood growth (van den Broek et al 2015); (Fernandez-Barres et al 2016); (Chatzi et al 2017); (Fernandez-Barres et al 2019)

    • childhood cardiometabolic health (Fernandez-Barres et al 2016); (Chatzi et al 2017); (Leermakers et al 2017)  

    • childhood wheeze (Castro-Rodriguez et al 2016); (Alvarez Zallo et al 2018); (Zhang et al 2019)

    Systematic reviews into vegan-vegetarian diets found inconsistency in results on birthweight, similar duration of pregnancy between vegan-vegetarian and omnivorous diets and a suggestion of risk of iron, vitamin B12 (Piccoli et al 2015) and zinc deficiency (Foster et al 2015); (Piccoli et al 2015) with vegan-vegetarian diets. 

    A systematic review found that fasting during Ramadan among well-nourished women did not increase the risk of preterm birth or low birthweight (Glazier et al 2018)

    Recommendation

    • Consensus-based
    • III

    Advise women that healthy dietary patterns are characterised by high intake of fruits, vegetables, legumes, wholegrains, fish, seafood, unprocessed meats, dairy foods and water. Diets with high intake of sweetened foods and drinks, foods high in saturated fats (eg fried foods), processed meats and refined grains are associated with poorer outcomes. Refer women to the Eat for Health website for further details. 

    Approved by NHMRC in Nov 2020; expires Nov 2025 

    Recent evidence on consumption of specific foods/food categories during pregnancy 

    The systematic review conducted to inform development of these Guidelines (Ramson et al 2020) found that the recent evidence on specific foods or food categories that should be promoted or avoided during pregnancy was generally observational but was consistent with the findings on dietary patterns.  

    Fruit, vegetables and legumes 

    There is evidence from observational studies that eating vegetables, fruit and legumes during pregnancy is beneficial to both mother and baby, with 

    • a reduction in risk of neural tube defects (OR 0.32; 95%CI 0.14 to 0.71; n=918) (Wang et al 2015a) 

    • possible associations with improvements in glucose tolerance (p<0.05; n=180) (Soto et al 2015), fetal growth (aOR 0.63; 95%CI 0.40 to 0.98; n=1,036) (Martinez-Galiano et al 2018), pre-eclampsia (aRR 0.20; 95%CI 0.04 to 0.98; p for trend=0.041; n=987) (Torjusen et al 2014); (Mi et al 2019), preterm birth (OR 0.67; 95%CI 0.50 to 0.91; n=923) (Smith et al 2015); (Chia et al 2016) and wheeze at 12 months (OR: 0.44; 95%CI 0.20 to 0.99; n=1,087) (Alvarez Zallo et al 2018).  

    Low fruit intake is associated with higher prevalence of major depressive disorder (PR 1.43, 95%CI 1.04 to 1.95; n=712) and low intake of legumes is associated with generalised anxiety disorder (PR 1.40, 95%CI 1.01 to 1.93; n=712) (n=712) (Paskulin et al 2017). A lower risk of childhood leukaemia is associated with maternal consumption of fruit (OR: 0.81, 95% CI: 0.67 to 0.99), vegetables (OR: 0.51, 95% CI: 0.28 to 0.94) and legumes (OR 0.76, 95% CI: 0.62 to 0.94) (n=903) (Dessypris et al 2017). Total daily fruit and vegetable consumption during pregnancy does not appear to be associated with maternal sleep duration (ß -0.03; 95%CI -0.07 to 0.00; n=2,951) (Duke et al 2017)

    Dairy 

    There is evidence from observational studies that higher maternal intake of all dairy products (255 vs 32 g/day) is associated with a reduced risk of eczema in babies (aOR 0.64; 95%CI 0.42 to 0.98) (Miyake et al 2015). Maternal milk intake is associated with reduced risk of neural tube defects (1-2 vs <1 time/week; OR 0.50; 95%CI 0.28 to 0.88; n=918) (Wang et al 2015a), asthma (OR 0.83; 95% CI 0.69 to 0.99; n=1,227), allergic rhinitis (OR 0.85; 95%CI 0.74 to 0.97; n=1,227) (Bunyavanich et al 2014) and cow’s milk allergy in children (OR 0.56, 95%CI 0.37 to 0.86; p<0.01; n=6,288) (Tuokkola et al 2016). Higher yoghurt intake (80 g vs 4 g a day) is associated with lower prevalence of depressive symptoms during pregnancy (aOR 0.69; 95%CI 0.48 to 0.99, p for trend 0.03; n=1,745) (Miyake et al 2015).  

    Potential allergens 

    There is evidence from observational studies that a lower risk of peanut allergy in the infant is associated with maternal peanut consumption during the first trimester (OR 0.53; 95%CI 0.30 to 0.94; n=1,227) (Bunyavanich et al 2014) or pre-pregnancy and during pregnancy (≥5 times vs <1 time per month: OR 0.31; 95% CI 0.13 to 0.75; P(trend)=0.004; n=8,205) (Frazier et al 2014). Maternal wheat intake during the second trimester may reduce atopic dermatitis in the infant (OR 0.64; 95%CI 0.46 to 0.90; n=1,227) (Bunyavanich et al 2014)

    Meat 

    There is evidence from observational studies that lower maternal meat consumption may be protective against wheeze in the child (p=0.039; n=1,000) (Castro-Rodriguez et al 2016) but that maternal intake of cured meats may be associated with a risk of childhood retinoblastoma (OR 5.07, 95 % CI 1.63 to 15.70; n=199) (Lombardi et al 2015)

    Fish 

    There is evidence from systematic reviews of observational studies that maternal fish intake may be associated with positive neurodevelopmental outcomes (qualitative review; 8 studies) (Starling et al 2015) and a reduced risk of childhood leukaemia (OR 0.27, 95% CI: 0.14 to 0.53; 2 studies) (Dessypris et al 2017). It does not appear to affect the risk of infant eczema (RR 0.88; 95%CI 0.75 to 1.04; 10 studies), wheeze (RR 0.94; 95%CI 0.83 to 1.07; 8 studies), allergic rhinitis (RR 0.95; 95%CI 0.62 to 1.45; 3 studies) or asthma (RR 0.94; 95%CI 0.75 to 1.18; 4 studies) (Zhang et al 2017).  

    Observational studies have found positive associations between maternal seafood intake during pregnancy and language and communication scales in the infant (n=38,351) (Vejrup et al 2018) and metabolic health of children (β = -0.96; 95%CI -1.49 to -0.42; n=805) (Stratakis et al 2020) but were inconsistent regarding the effect on child growth (Stratakis et al 2016); (van den Berg et al 2016)

    There is evidence from observational studies that low intake of seafood may be associated with increased risk of antenatal depression (aOR 1.54; 95%CI 1.25 to 1.89; n=12,418) (Emmett et al 2015).  

    A cohort study (n=3,279) (Mohanty et al 2016) found a possible association between lean fish intake and preterm birth (RR 1.55; 95% CI 1.04 to 2.30). The study noted that studies of mechanisms and potential contributing factors (including seafood preparation and nutrient contaminant content) are warranted. There was no association between fatty fish intake and preterm birth and no association between other pregnancy complications and either lean or fatty fish consumption.  

    While fish consumption during pregnancy may have benefits for the women and child, high fetal exposure to mercury through maternal fish consumption is associated with low birthweight (MD -34 g; 95%CI -46 g to -22 g; n=56,988) and small-for-gestational age (aOR 1.19; 95%CI 1.08 to 1.30; n=56,988) (Vejrup et al 2014), delayed language and communication skills in a generally low exposed population (n=46,750 mother-child pairs) (Vejrup et al 2016) and an unfavourable metabolic profile in children (β per 2-fold increase in mercury concentration 0.18; 95% CI 0.01 to 0.34) (Stratakis et al 2020). Types of fish that should be avoided during pregnancy due to potential high mercury content are listed in Table C2. 

    Carbohydrates 

    There is RCT evidence that, in obese women with impaired glucose tolerance, a lower carbohydrate intake in late pregnancy is associated with a lower fat mass in the baby at birth (188 vs 238 g/day; ptrend=0.006; n=222) (Renault et al 2015a). There is evidence from cohort studies that high maternal carbohydrate consumption may be associated with increases in birthweight (4g for each additional 10 g/day; 95%CI 1.0 to 7.0; p=0.003; n=1,196) (Sharma et al 2018) and with infant wheeze (potatoes once or twice a week OR 1.75; 95%CI 1.22 to 2.51; n=1,087; pasta never or occasionally; p=0.049) (Castro-Rodriguez et al 2016); (Alvarez Zallo et al 2018)

    Protein 

    There is evidence from observational studies that maternal protein intake may be associated with a higher risk of gestational diabetes (OR highest vs lowest quartile of intake 2.15; 95% CI 1.27 to 3.62; p=0.016; n=980) (Pang et al 2017), may increase fat-free mass in the infant (ß 0.14; 95 % CI 0.03 to 0.25 for highest vs lowest quartile of intake; n=2,694 mother-child pairs) (Tielemans et al 2017), may reduce newborn abdominal adipose tissue (-0.18 mL; 95%CI -0.35 to -0.001 mL per 1% protein-to-carbohydrate substitution and -0.25 mL; 95%CI 0.46 to -0.04 mL per 1% protein-to-fat substitution; n=320 mother-child pairs) (Chen et al 2016) and may reduce early length growth (0.09 cm/year 6 months to late childhood; 95% CI: -0.14 to -0.05; n=1,961) (Switkowski et al 2016)

    Fats 

    There is evidence from observational studies that women with uncomplicated pregnancies had lower daily fat intake (32.1%) than women who developed gestational diabetes (36.2%) (p=0.0251; n=55) (Mizgier et al 2019) and that an additional 10 g/day fat intake was associated with a lower birthweight (MD -8 g; 95%CI -16 to -0.3; p=0.04; n=1,196), with the authors concluding that balancing intake of dietary carbohydrate and fat during pregnancy could support optimal birthweight (Sharma et al 2018)

    Sweetened foods and drinks 

    There is evidence from an RCT that higher consumption of foods and drinks that contribute to intake of added sugars (2 times daily versus <1 time/week) is associated with higher gestational weight gain (MD 5.4 kg; 95% CI 2.1 to 8.7; n=342) (Renault et al 2015b). Observational studies report an association between sugar-sweetened foods and drinks and impaired glucose tolerance (p<0.05; n=180) (Soto et al 2015) and gestational diabetes (aOR for highest vs lowest category 2.03; 95%CI 1.25 to 3.31; n=3,396) (Donazar-Ezcurra et al 2018). It is also associated with an increased prevalence of major depressive disorder (adjusted prevalence ratio [aPR] 1.91; 95%CI 1.19 to 3.07; n=712) (Paskulin et al 2017).  

    Fetal and child growth is also affected by higher intake of sweetened foods and drinks, with increased risks of large for gestational age (aRR 1.57; 95%CI 1.05 to 2.35; n=918 mother-child pairs) (Zhu et al 2017), increased infant BMI z score (0.20-unit increase in infant BMI z score; 95% CI 0.02 to 0.38; n=2,686) and overweight at 1 year (aOR 2.19; 95%CI 1.23 to 3.88,686) (Azad et al 2016) and 7 years of age (aRR 1.93; 95%CI 1.24 to 3.01; 918 mother-child pairs) (Zhu et al 2017). Maternal consumption of sweetened foods and beverages is also associated with infant atopy (OR for highest versus lowest quintile of sugar intake 1.38, 95%CI 1.06 to 1.78; per quintile p-trend=0.006; n=8,956) and asthma (OR 2.01, 95% CI 1.23-3.29; per quintile p-trend=0.004 n=8,956) (Bedard et al 2017)

    Fast foods 

    There is evidence from cohort studies that ‘fast food’ (eg ready-to-eat food and drinks that are typically higher in energy (kilojoules), low in nutrition and prepared away from home) consumption is associated with an increased risk of gestational diabetes (aOR for high vs low consumption 1.86; 95% CI 1.13 to 3.06; n=3,048) (Dominguez et al 2014), infant eczema (p=0.005; n=1,000) (Castro-Rodriguez et al 2016) and asthma (RR 4.46; 95%CI 1.36 to 14.6; n=1,201 mother-child pairs) (von Ehrenstein et al 2015). A small case-control study found a positive association between maternal intake of fried foods and retinoblastoma in the child (OR 4.89, 95 % CI 1.72 to 13.89; n=299) (Lombardi et al 2015)

    Caffeine 

    There is insufficient evidence to confirm or refute the effectiveness of caffeine avoidance on birth weight or other pregnancy outcomes (Jahanfar & Jaafar 2015). Food Standards Australia and New Zealand suggests limiting intake during pregnancy to 200 mg of caffeine (FSANZ 2019), noting that caffeine is present in coffee, tea, colas, energy drinks and chocolate. 

    There is evidence from observational studies that the risks of preterm birth (OR per 100 mg/d caffeine increase 1.28; 95%CI 1.03 to 1.58; P=0.03; n=858) (Okubo et al 2015) and childhood brain tumours (OR ≥2 cups per day 2.52; 95% CI 1.26 to 5.04; n=1,019) (Greenop et al 2014) increase with caffeine intake.  

    11.2 Nutritional supplements

    Dietary patterns consistent with the Australian Dietary Guidelines will allow the general population to meet nutrient requirements. However, the recommended dietary intake is higher for some nutrients during pregnancy ((NHMRC & NZ Ministry of Health 2020)) and supplementation of some nutrients (eg folic acid and iodine) is recommended. Some women may also seek advice on other supplements.  

    11.2.1 Vitamins

    Pregnancy multivitamins 

    Background  

    In Australian observational studies: 

    • 79% of pregnant women used multivitamin supplements (Shand et al 2016)

    • 42% of participants used pregnancy multivitamins, with 26.8% using multivitamins in combination with individual micronutrients and 9.8% using specific micronutrient supplements; nulliparous women were more likely to take supplements (McAlpine et al 2020)

    • 83% of women took a multivitamin during pregnancy, with 90% of women with post-secondary education and 64% of women with secondary education only using these supplements (Malek et al 2018)

    • pregnancy-specific multivitamin use was reported by 47% of women in the first trimester, 51% in the second trimester and 46% in the third trimester and general multivitamin use was reported by 31% of women in the first trimester, 27% in the second trimester and 35% in the third trimester (Livock et al 2017)

    Summary of recent evidence 

    There is very low to low certainty evidence that antenatal multivitamin supplementation among women in high income countries is associated with a reduced risk of small for gestational age (RR 0.77; 95%CI 0.63 to 0.93; 3 cohort studies; very low certainty) and some congenital anomalies and a possible reduced risk of preterm birth (RR 0.84; 95%CI 0.69 to 1.03; 4 cohort studies; very low certainty) (Wolf et al 2017)

    Recommendation

    • Practice point
    • H

    Many pregnant women take a multivitamin supplement from early pregnancy or while trying to conceive. These supplements contain most of the individual vitamins/minerals discussed below, so when providing advice, health professionals need to ask, and take into account, which multivitamins a woman is already taking or planning to take. 

    Approved by NHMRC in Nov 2020; expires Nov 2025 

    Folic acid (vitamin B9) 

    Background 

    A survey of pregnant women conducted in Sydney found that 30.6% were taking a supplement of folic acid alone (Shand et al 2016). A cross-sectional study that included national and South Australian cohorts found that, while awareness of recommendations on folic acid supplementation was high (90%), adherence was low (27%) (Malek et al 2016a)

    In an Australian cohort study (Livock et al 2017), 19-46% of women did not meet the recommended daily intake for folate. Conversely, 15-19 % of women consumed beyond the recommended upper limit for folate.  

    Dietary sources of folate include green vegetables (eg spinach), legumes, rice, avocado, fruit, beef liver and fortified products (many breakfast cereals, bread, fruit juice, vegemite). 

    Summary of the evidence 

    There is high certainty evidence that folic acid supplementation ≥400 µg per day preconception and in the first 3 months of pregnancy is associated with a reduction in risk of neural tube defects (RR 0.32; 95%CI 0.17 to 0.60; 4 RCTs; n=6,708) (De-Regil et al 2015). There was no evidence of any preventive or negative effects on other congenital anomalies. 

    Evidence from observational studies suggests it may reduce congenital heart defects (RR 0.72; 95%CI 0.63 to 0.82 (Feng et al 2015); OR 0.60; 95%CI 0.49 to 0.71 (Xu et al 2016).  

    There is evidence from systematic reviews of observational studies that folic acid supplementation during pregnancy may reduce the risk of acute myeloid leukaemia (OR 0.52; 95%CI 0.31 to 0.89) (Metayer et al 2014), brain and spinal cord tumours in the child (OR 0.77; 95%CI 0.66 to 0.90) (Chiavarini et al 2018) and autism spectrum disorders (RR 0.77; 95%CI 0.64 to 0.93, 16 studies) (Wang et al 2017)

    The evidence suggests that folic acid supplementation during pregnancy does not affect the risk of early or late miscarriage (RR 0.97; 95%CI 0.65 to 1.44; 1 RCT; n=903), stillbirth (RR 0.67; 95%CI 0.11 to 4.02; 1 RCT; n=903), total fetal loss (RR 0.95; 95%CI 0.64 to 1.40; 1 RCT; n=903) (Balogun et al 2016), preterm birth (RR 0.99; 95%CI 0.82 to 1.18; 1 RCT; n=1,654 (Saccone & Berghella 2016); RR 1.09; 95%CI 0.77 to 1.54; 1 RCT; n=2,797 (Lassi et al 2013), low birthweight (RR 0.79; 95%CI 0.49 to 1.28; 4 RCT; n=4,453 (Saccone & Berghella 2016); RR 0.80; 95%CI 0.63 to 1.02; 3 studies; n=3,089 (Lassi et al 2013), infant asthma (RR 1.04; 95%CI 0.94 to 1.16; 3 observational studies) or infant wheeze (RR 1.04; 95%CI 0.94 to 1.16; 3 observational studies) (Wang et al 2015b).  

    There is inconclusive evidence on the effect of folic acid supplementation on gestational hypertension, pre-eclampsia {{Hua et al 2016; Bulloch et al 2018; (Liu et al 2018a); (Wen et al 2018) and acute lymphoblastic leukaemia in the infant (Metayer et al 2014); (Dessypris et al 2017)

    Recommendation

    • Evidence-based
    • 5

    Advise dietary supplementation of 400 µg per day folic acid, ideally from 1 month before conception and throughout the first 3 months of pregnancy to reduce the risk of neural tube defects. 

    Approved by NHMRC in Nov 2020; expires Nov 2025 

    Other vitamins

    • Vitamin B6: There is insufficient evidence to detect clinical benefits in pregnancy (Salam et al 2015), although it appears to be of benefit in reducing nausea (MD in nausea score -3.7; 95%CI -6.9 to -0.5; very low certainty) (Sridharan & Sivaramakrishnan 2018). See also Chapter 54. 

    • Vitamin B12: The evidence on vitamin B12 supplementation in pregnancy is of insufficient certainty to draw conclusions. However, it may be of benefit for women with vegetarian or vegan diets, as vitamin B12 is generally not present in plant foods (Pawlak et al 2014). See also Chapter 30. 

    • Vitamin C: The evidence does not support routine high dose (1,000 mg/day) vitamin C supplementation for fetal loss (RR 1.28; 95%CI 0.58 to 2.83; 2 RCTs; n=224) (Balogun et al 2016) or perinatal death (RR 0.51; 95%CI 0.05 to 5.54; 1 RCT; n=182) (Rumbold et al 2015b), intrauterine growth restriction (RR 1.56; 95%CI 0.63 to 3.89; 1 RCT; n=159; high certainty), preterm birth (RR 1.06; 95%CI 0.75 to 1.48; 5 RCTs; n=1,685; high certainty) or pre-eclampsia (RR 0.88; 95%CI 0.48 to 1.61; 3 RCTs; n=1,191) (Rumbold et al 2015b). Further research is required to clarify the possible role of vitamin C in the prevention of placental abruption and prelabour rupture of membranes (Rumbold et al 2015b).  

    • Vitamin D: Vitamin D supplementation may be a consideration for women with vitamin D levels lower than 50 nmol/L. The evidence for vitamin D supplementation is discussed in Chapter 47. 

    • Vitamin E: The evidence on vitamin E supplementation during pregnancy is of insufficient certainty to draw conclusions on efficacy and safety (Fu et al 2018)

    • Vitamins C and E combined: Supplementation with vitamins C and E (500 to 1,000 mg vitamin C plus 400 IU vitamin E) during pregnancy appears to reduce the risk of placental abruption (RR 0.64; 95% CI 0.44 to 0.93, 7 RCTs, n=14,922; high certainty) but increases the risk of term prelabour rupture of the membranes (RR 1.77; 95% CI 1.37 to 2.28, 2 RCTs, n=2,504) (Rumbold et al 2015a). It does not appear to affect other perinatal outcomes (Rumbold et al 2015a); (Balogun et al 2016); (Vahdaninia M. et al 2017); (Fu et al 2018); (Tenorio et al 2018). Combined vitamins C and E may reduce the risk of preterm birth (RR 0.76; 95% CI 0.58 to 0.99) and placental abruption (RR 0.09; 95% CI 0.00 to 0.87) in pregnant women who smoke (Abramovici et al 2015)

    • Vitamin A: The evidence does not support vitamin A supplementation for the prevention of fetal loss (RR 1.05; 95%CI 0.90 to 1.23; 3 RCTs; n=52,480) (Balogun et al 2016), maternal mortality (RR 0.88; 95%CI 0.65 to 1.20; 4 RCTs; n=154,039; high certainty), perinatal mortality (RR 1.01; 95%CI 0.95 to 1.07; 1 RCT, n=76,178; high certainty) or preterm birth (RR 0.98; 95%CI 0.94 to 1.01; 5 RCTs, n=48,007; high certainty) (McCauley et al 2015). The evidence on the role of vitamin A supplementation in reducing risk of maternal clinical infection (RR 0.45; 95%CI 0.20 to 0.99; 5 RCTs; n=17,313; low certainty) and preventing anaemia (RR 0.64; 95%CI 0.43 to 0.94; 3 RCTs; n=15,649; moderate certainty) (McCauley et al 2015) may not be generalisable to the Australian context.  

    Recommendation

    • Evidence-based
    • 6

    Advise women that, in the absence of an identified deficiency, taking high-dose supplements of vitamin A, C or E is of little or no benefit in pregnancy and may cause harm. 

    Approved by NHMRC in Nov 2020; expires Nov 2025 

    11.2.2 Minerals 

    Iron 

    Background 

    Studies have investigated rates of iron intake, supplementation and iron-deficiency anaemia among Australian women during pregnancy. In a cohort study ((Livock et al 2017)) 68-82% of women did not meet the recommended daily intake level for iron; conversely, 11-24% of women consumed beyond the recommended upper limit for iron. Cross-sectional studies have found that levels of iron-only supplementation are relatively low in general (7-30%) (Chatterjee et al 2016); (Shand et al 2016) and among women with diagnosed iron deficiency (65%) or with diagnosed iron-deficiency anaemia (62%) (Chatterjee et al 2016)

    Studies among Aboriginal and Torres Strait Islander women have found very low levels of women meeting the estimated average requirement for iron in some areas (Lee et al 2018c) and high levels of iron deficiency and anaemia (Leonard et al 2018)

    Iron-rich staple foods include meat, seafood, poultry and wholegrains (NHMRC & NZ Ministry of Health 2020). Iron in foods can come in two general forms — as haem or non-haem iron. Iron from animal food sources may be either haem or non-haem whereas the iron in plant sources such grains and vegetables is non-haem (NHMRC & NZ Ministry of Health 2020). The haem form is more bioavailable to humans than the non-haem. Absorption is aided by vitamin C and limited by tea and coffee (Marsh et al 2009). Where iron-rich foods are not available (eg due to geographical location or socioeconomic factors), women may be at high risk of iron deficiency.  

    Summary of the recent evidence 

    There is moderate certainty evidence that preventive iron supplementation in pregnancy may reduce the risk of preterm birth (RR 0.93; 95%CI 0.84 to 1.03, 13 RCTs, n=19,286) (Peña-Rosas et al 2015); (Abraha et al 2019).  

    There is low certainty evidence that iron supplementation in pregnancy reduces the risk of maternal anaemia at term (RR 0.30; 95%CI 0.19 to 0.46, 14 RCTs, n=2,199 (Peña-Rosas et al 2015); RR 0.38; 95% CI 0.27 to 0.33; 13 RCTs (Abraha et al 2019) and iron deficiency at term (RR 0.43; 95%CI 0.27 to 0.66, 7 RCTs, n=1,256) (Peña-Rosas et al 2015). There is also low certainty evidence that iron supplementation has no clear effect on neonatal death (RR 0.91; 95%CI 0.71 to 1.18, 4 RCTs, n=16,603 (Peña-Rosas et al 2015); RR 0.93; 0.72 to 1.20; 7 RCTs (Abraha et al 2019), low birthweight (RR 0.84; 95%CI 0.69 to 1.03; n=17,613; 11 RCTs (Peña-Rosas et al 2015); RR 0.94, 95% CI 0.79 to 1.13; 7 RCTs (Abraha et al 2019) or congenital anomalies (RR 0.88, 95%CI 0.58 to 1.33, 4 RCTs, n=14,636) (Peña-Rosas et al 2015).  

    There is very low certainty evidence that iron supplementation in pregnancy has no clear effect on the risk of maternal death (RR 0.33; 95%CI 0.01 to 8.19, 2 RCTs, n=12,560) (Peña-Rosas et al 2015) or maternal adverse effects (RR 1.29; 95%CI 0.83 to 2.02, 11 RCTs, n=2,423 (Peña-Rosas et al 2015); RR 1.42; 95%CI 0.91 to 2.21; 12 RCTs (Abraha et al 2019). A systematic review indicates that iron supplementation has no clear effect on infant neurodevelopment (MD 0.54 units across different measures; 95% CI -0.67 to 1.75; 3 RCTs) (Jayasinghe et al 2018)

    There is low certainty evidence that weekly (80-300 mg elemental iron) versus daily (30-60 mg elemental iron) supplementation in pregnancy has no clear effect on preterm birth (RR 1.03; 95%CI 0.76 to 1.39; n=1,177; 5 RCTs), birthweight (MD 5.13 g; 95%CI -29.46 to 39.72; n=1,939; 9 RCTs) or low birthweight (RR 0.82; 95%CI 0.55 to 1.22; n=1,898; 8 RCTs) (Pena-Rosas et al 2015).  

    There is very low certainty evidence that maternal adverse effects such as constipation and nausea (RR 0.56; 95%CI 0.37 to 0.84; n=1,777; 1 RCT) are reduced with weekly versus daily iron supplementation with no clear effect on the risk of maternal anaemia at term (RR 1.22; 95%CI 0.84 to 1.80; n=676; 4 RCTs), maternal iron-deficiency at term (RR 0.71; 95%CI 0.08 to 6.63; 1 RCT) or neonatal death (RR 0.49; 95%CI 0.04 to 5.42; n=795; 1 RCT) (Pena-Rosas et al 2015)

    Recommendation

    • Evidence-based
    • 7

    Advise iron supplementation to pregnant women based on their haemoglobin concentration at 28 weeks (see Chapter 30). 

    Approved by NHMRC in Nov 2020; expires Nov 2025 

    There is low certainty evidence that weekly (80-300 mg elemental iron) versus daily (30-60 mg elemental iron) supplementation in pregnancy has no clear effect on preterm birth (RR 1.03; 95%CI 0.76 to 1.39; n=1,177; 5 RCTs), birthweight (MD 5.13 g; 95%CI -29.46 to 39.72; n=1,939; 9 RCTs) or low birthweight (RR 0.82; 95%CI 0.55 to 1.22; n=1,898; 8 RCTs) (Pena-Rosas et al 2015).  

    There is very low certainty evidence that maternal adverse effects such as constipation and nausea (RR 0.56; 95%CI 0.37 to 0.84; n=1,777; 1 RCT) are reduced with weekly versus daily iron supplementation with no clear effect on the risk of maternal anaemia at term (RR 1.22; 95%CI 0.84 to 1.80; n=676; 4 RCTs), maternal iron-deficiency at term (RR 0.71; 95%CI 0.08 to 6.63; 1 RCT) or neonatal death (RR 0.49; 95%CI 0.04 to 5.42; n=795; 1 RCT) (Pena-Rosas et al 2015).  

    Recommendation

    • Evidence-based
    • 8

    Advise pregnant women taking an iron supplement that weekly supplementation (80-300 mg elemental iron) is as effective as daily supplementation (30-60 mg elemental iron) in preventing (but not treating) iron-deficiency anaemia, with fewer adverse effects. 

    Approved by NHMRC in Nov 2020; expires Nov 2025 

    Recommendations for testing and treatment of iron-deficiency anaemia are included in Chapter 30. 

    Calcium 

    Background 

    A survey of pregnant women conducted in Sydney found that 13% were taking a supplement of calcium alone (Shand et al 2016)

    Calcium is found predominantly in milk and milk-based foods, with smaller amounts in bony fish, legumes and most nuts, fortified soy beverages and breakfast cereals (NHMRC & NZ Ministry of Health 2020). 

    Calcium requirements during pregnancy are higher among adolescent women than among women older than 18 years (NHMRC & NZ Ministry of Health 2020). 

    Summary of recent evidence 

    There is consistent evidence from systematic reviews that calcium supplementation reduces the risk of gestational hypertension (Hofmeyr et al 2018); (Sun et al 2019) and pre-eclampsia (Hofmeyr et al 2014); (Khaing et al 2017); (Hofmeyr et al 2018); (Sun et al 2019)).  

    High-dose calcium supplementation (≥1 g/day) reduces the risk of gestational hypertension (RR 0.65; 95%CI 0.53 to 0.81; 12 RCTs; n=15,470), with a clearer effect among women with low dietary calcium (RR 0.44; 95%CI 0.28 to 0.70; 7 RCTs; n=10,418) than among women with adequate dietary calcium (RR 0.90; 95%CI 0.81 to 0.99; 4 RCTs; n=5,022) (Hofmeyr et al 2018). High-dose calcium also reduces the risk of pre-eclampsia (RR 0.45; 95CI 0.31 to 0.65; 13 trials; n=15,730; low certainty).  

    Low-dose calcium (<1 g/day) also reduces the risk of gestational hypertension (RR 0.57; 95%CI 0.39 to 0.82; 3 RCTs; n=558) (Hofmeyr et al 2018) and pre-eclampsia (RR 0.36; 95%CI 0.23 to 0.57; 4 RCTs; n=980) (Hofmeyr et al 2014)

    A Cochrane review (Hofmeyr et al 2018) found a possible reduction in risk of preterm birth <37 weeks with high-dose calcium among all women (RR 0.76; 95%CI 0.60 to 0.97; 11 trials, n=15,275; low certainty). Another Cochrane review of calcium supplementation trials not specifically targeted at preventing pre-eclampsia (Buppasiri et al 2015) found no clear difference in risk of preterm birth at <37 weeks (RR 0.86; 95% CI 0.70 to 1.05; 13 studies, n=16,139; moderate certainty) or at <34 weeks (RR 1.04; 95%CI 0.80 to 1.36; 4 RCTs, n=5,669; moderate certainty). 

    Calcium supplementation does not appear to be of benefit in preventing low birthweight (RR 0.93; 95%CI 0.81 to 1.07; 6 RCTs; n=14,162; moderate certainty) (Buppasiri et al 2015).  

    A systematic review found no difference in rates of adverse effects between women taking calcium supplements and those taking a placebo (Buppasiri et al 2015). 

    There is some evidence that routine calcium supplementation in pregnancy in high-income countries such as the Netherlands is more cost-effective than selective supplementation (Meertens et al 2018)

    Recommendation

    • Evidence-based
    • 9

    Advise pregnant women at risk of hypertension to take a calcium supplement. 

    Approved by NHMRC in Nov 2020; expires Nov 2025 

    Iodine 

    Background 

    The NHMRC (2010) Public Statement: Iodine Supplementation for Pregnant and Breastfeeding Women suggests pregnant women take an iodine supplement of 150 µg each day to avoid poor infant neurodevelopment.  

    Evidence of iodine deficiency re‐emerged in Australia in the 1990s, motivating mandatory fortification of bread with iodised salt in 2009. The AIHW reports that, while mandatory fortification delivered sufficient amounts of iodine to the general population, intakes for many pregnant and breastfeeding women were insufficient due to their increased requirements (AIHW 2016)

    In a review of Australian cohort studies post-fortification (7 studies) (Hurley et al 2019), three studies found that the pregnant women in their studies were iodine replete and four studies found that pregnant women were in the mild-to-moderate iodine deficiency category. Only two studies documented iodine sufficiency among pregnant women in the absence of iodine supplementation.  

    A survey of pregnant women conducted in Sydney found that 6.3% were taking an iodine supplement (Shand et al 2016). A study conducted in Gippsland Victoria, a mildly iodine deficient area, found that only 18.9% of participants followed the NHMRC advice, with 42.3% of participants not taking any supplements (or supplements with no iodine or insufficient iodine) (Mitchell et al 2018). The remaining women (38.7%) were taking supplements with doses of iodine much higher (200-300 μg) than the NHMRC recommended dose or were taking multiple supplements containing iodine. In a South Australian study, 85.9% women met the estimated average requirement (≥160 μg/day) for iodine intake from food and supplements (Condo et al 2017). When iodine from supplements was excluded, 44.5% of women met the estimated average requirement for iodine intake during pregnancy. In a Western Australian study, 66% of pregnant women were taking iodine supplements (Hine et al 2018). A Tasmanian study (n=255) found that, despite recommendations for iodine supplementation, pregnant Tasmanian women remain at risk of iodine deficiency (Hynes et al 2019)

    An analysis of cross-sectional data from two Australian longitudinal studies pre- and post-fortification of iodine (n=368) (Singh et al 2019) found that the median urinary iodine concentration of pregnant Indigenous women in remote locations remains low and targeted interventions are needed to ensure healthy fetal development. In a cross-sectional study in Western Australia (n=425) (Sherriff et al 2019) ethnicity was associated with iodised salt use, with 76% of Asian women used iodised salt compared with 33% of Caucasian women.  

    In a national survey of maternity care providers, while 71% were aware of the NHMRC advice on iodine supplementation, fewer were aware of the recommended dose (38%) or duration (44%), with 73% advising iodine supplements in pregnancy (Guess et al 2017)

    Summary of recent evidence 

    There is low certainty evidence that, in settings with mild to moderate iodine deficiency, iodine supplementation may reduce the risk of postpartum hyperthyroidism (average RR 0.32; 95%CI 0.11 to 0.91; three RCTs; n=543 women) with very low certainty evidence of an increased likelihood of gastrointestinal intolerance during pregnancy (average RR 15.33; 95%CI 2.07 to 113.70; one RCT; n=76) (Harding et al 2017). There is low certainty evidence that iodine supplementation has any effects on other outcomes or side effects for mothers or infants (Harding et al 2017); (Farebrother et al 2018).  

    RCTs have reported that iodine supplementation: 

    • increased maternal urinary iodine levels in areas with iodine deficiency (p<0.05) (Chawanpaiboon 2019) and mild-moderate deficiency (p<0.0001) (Censi et al 2019) 

    • decreased maternal thyroglobulin levels (p=0.02) (Censi et al 2019) 

    • decreased median neonatal thyroid stimulating hormone levels (p<0.05) (Chawanpaiboon 2019) 

    • had no effect on child neurodevelopment at age 5–6 years in mildly iodine-deficient pregnant women (Gowachirapant et al 2017)

    Recommendation

    • Consensus-based
    • IV

    Suggest that pregnant women take an iodine supplement of 150 µg each day. Women with pre-existing thyroid conditions should seek advice from their medical practitioner before taking a supplement. 

    Approved by NHMRC in Nov 2020; expires Nov 2025 

    Zinc 

    Background 

    A survey of pregnant women conducted in Sydney found that 5.6% were taking a zinc supplement (Shand et al 2016). In an Australian cohort study (Livock et al 2017) 17-24% of pregnant women did not meet the recommended daily intake for zinc.  

    Summary of recent evidence 

    There is some evidence that zinc supplementation may slightly reduce the risk of preterm birth with no clear effect on low birthweight or other outcomes, possibly indicating that low zinc status reflects poorer overall nutrition in some pregnant women (Ota et al 2015); (Liu et al 2018b). Zinc supplementation does not appear to increase or reduce the risk of other outcomes (Nossier et al 2015); {{Ota et al 2015; (Zahiri Sorouri et al 2016); (Oh et al 2020).  

    Other minerals 

    • There is insufficient high-certainty evidence to show whether dietary magnesium supplementation during pregnancy is beneficial (Makrides et al 2014)

    • There is insufficient evidence to draw conclusions on selenium supplementation in pregnancy (Tara et al 2010); (Rayman et al 2014)

    11.2.2 Other nutritional supplements 

    Other multiple micronutrients 

    Summary of recent evidence 

    There is high certainty evidence from studies conducted in low- to middle-income countries that the use of multiple micronutrients (including iron and folic acid) during pregnancy reduces the risk of low birthweight and may reduce the risk of stillbirth but does not affect the risk of perinatal or neonatal mortality (Keats et al 2019). There is moderate certainty evidence of a reduction in risk of small for gestational age and a possible reduction in risk of preterm birth (<37 weeks) (Keats et al 2019). There is evidence that multiple micronutrient use is associated with a reduction in risk of early preterm birth (<34 weeks), a possible reduction in risk of miscarriage, with no effect on maternal mortality, maternal anaemia, caesarean section or congenital anomalies (Keats et al 2019). These findings may not be generalisable to the Australian context. 

    Omega-3 fatty acids 

    Background 

    Omega-3 fatty acids are found predominantly in oily fish such as mackerel, herrings, sardines, salmon and tuna (NHMRC & NZ Ministry of Health 2020)

    In an Australian cross-sectional study, 12% of women took fish oil during pregnancy (Shand et al 2016)

    Summary of the evidence 

    There is high certainty evidence that rates of preterm birth <37 weeks (10.1% versus 8.1%%; RR 0.89, 95%CI 0.82 to 0.97; 30 RCTs, n=21,271) and early preterm birth <34 weeks (2.6% vs 1.6%; RR 0.64, 95%CI 0.44 to 0.93; 11 RCTs, n=15,750) are lower in women receiving omega-3 long-chain polyunsaturated fatty acids compared with no omega-3 (Middleton et al 2018). There is moderate-certainty evidence that prolonged pregnancy >42 weeks is probably increased with omega-3 fatty acid supplementation (RR 1.61 95%CI 1.11 to 2.33; n=5,141; 6 RCTs) but insufficient evidence to determine the effect of supplementation on induction post-term (Middleton et al 2018). There is high certainty evidence of a reduced risk of low birthweight (15.6% vs 14%; RR 0.90, 95%CI 0.82 to 0.99; 15 trials, n=8,449;) and moderate certainty evidence for a possible reduced risk of perinatal death (RR 0.75, 95%CI 0.54 to 1.03; 10 RCTs, n=7,416), neonatal care admission (RR 0.92, 95%CI 0.83 to 1.03; 9 RCTs, n=6,920) and a possible small increase in risk of large-for-gestational age babies (RR 1.15, 95%CI 0.97 to 1.36; 6 RCTs, n=3,722) with omega-3 fatty acid supplementation (Middleton et al 2018).  

    The large ORIP (Omega-3 fats to Reduce the Incidence of Prematurity) trial (Makrides et al 2019) used a dose of 800 mg docosahexaenoic acid (DHA) and 100 mg eicosapentaenoic acid (EPA) per day. Further analysis of this trial indicates that women with low omega-3 status will benefit most from supplementation with omega-3 (Simmonds et al 2020)

    Recommendation

    • Evidence-based
    • 10

    Advise pregnant women that supplementation with omega-3 long-chain polyunsaturated fatty acids (800 mg DHA and 100 mg EPA per day) may reduce their risk of preterm birth, if they are low in omega-3.  

    Approved by NHMRC in Nov 2020; expires Nov 2025 

    Probiotics 

    A meta-analysis of RCTs conducted to inform these Guidelines (Ramson et al 2020) found low certainty evidence that supplementation with probiotics may be associated with a possible reduction in caesarean section (RR 0.92; 95%CI 0.81 to 1.05; 15 RCTs; n=2,650), and very low certainty evidence of a reduction in Group B streptococcus colonisation (RR 0.76; 95%CI 0.61 to 0.97; n=244) and a possible reduction in risk of gestational diabetes (RR 0.87; 95%CI 0.71 to 1.08; 8 RCTs; n=1,722).  

    There is very low or low certainty evidence that probiotic supplementation does not reduce gestational hypertension (RR 1.24; 95%CI 0.74 to 2.06; 4 RCTs; n=955), pre-eclampsia (RR 1.88; 95%CI 0.96 to 3.71; 2 RCTs; n=598), bacterial vaginosis (RR 1.73; 95%CI 0.89 to 3.38; 2 RCTs; n=509), perinatal death (RR 1.17; 95%CI 0.62 to 2.24; 6 RCTs; n=1,670), preterm birth (RR 1.10; 95%CI 0.81 to 1.50; 16 RCTs; n=3,671), small for gestational age (RR 1.04; 95%CI 0.55 to 1.94; 3 RCTs; n=318), large for gestational age (RR 0.95; 95%CI 0.47 to 1.93; 3 RCTs; n=316) or macrosomia (RR 1.06; 0.85 to 1.33; 7 RCTs; n=1,407). 

    Herbal preparations 

    Background 

    An Australian cohort study (n=1,835) found that 34.4% of women were using herbal preparations during pregnancy, of whom 77.9% were self-prescribing these products (Frawley et al 2015). Women were more likely to use herbal medicine if they had anxiety (OR 1.30; 95%CI, 1.02 to 1.64; p=0.031), sleeping problems (OR 1.55; 95%CI 1.15 to 2.11; p=0.005) or fatigue (OR 1.32; 95%CI 1.04 to 1.68; p=0.025) and less likely to use herbal medicine if they had nausea (OR 0.71; 95% CI 0.56 to 0.91; p=0.007). Women who used herbal preparations viewed them as a preventative measure, were looking for something holistic and were concerned about evidence of clinical efficacy when considering the use of these products during pregnancy (Frawley et al 2016).  

    Each herbal preparation needs to be considered as a potentially unique therapeutic agent, different in action from any other herbal medicine; even those within the same genus or produced from different parts of the same plant. The use of herbal preparations by pregnant women should be supervised by an appropriately qualified health professional. 

    Summary of the evidence 

    The evidence on the efficacy and safety of herbal preparations during pregnancy is limited. There is moderate certainty evidence that ginger reduces nausea (MD -4.2 nausea score; 95%CI -6.5 to -1.9), with a low risk of adverse effects (OR 0.4; 95%CI 0.1 to 0.9) (Sridharan & Sivaramakrishnan 2018). There is very low certainty evidence that chamomile is also effective in reducing nausea (MD -4.2; 95%CI -6.7 to -1.7; 1 RCT(Sridharan & Sivaramakrishnan 2018). There is evidence from a systematic review that garlic may reduce gestational hypertension (RR 0.50; 95%CI 0.25 to 1.00) but does not affect the risk of pre-eclampsia (RR 0.78, 95% CI 0.31 to 1.93) or caesarean section (RR 1.35, 95% CI 0.93 to 1.95), with odour likely to be experienced (RR 8.50, 95%CI 2.07 to 34.88) (Meher & Duley 2006). There is insufficient evidence on the efficacy and safety of echinacea, raspberry leaf, elderberry and St John’s wort during pregnancy (Deligiannidis et al 2014); (Holst et al 2014); (Munoz Balbontin et al 2019).  

    Recommendation

    • Consensus-based
    • V

    Advise women that the effectiveness and safety of herbal preparations varies according to the herbal preparation and the condition being treated.  

    Approved by NHMRC in Nov 2020; expires Nov 2025 

    11.3 Physical activity 

    11.3.1 Background 

    Physical activity can be defined as any movement that expends energy. This includes sport, exercise and recreational activities and incidental activity that accrues throughout the day (eg walking to the shops, climbing stairs). 

    The Australian Physical Activity and Sedentary Behaviour Guidelines (DoH 2014) recommend that adults aged 18-64 years: 

    • accumulate 150 to 300 minutes (2½ to 5 hours) of moderate intensity physical activity or 75 to 150 minutes (1¼ to 2½ hours) of vigorous intensity physical activity, or an equivalent combination of both moderate and vigorous activities, each week 

    • do muscle strengthening activities on at least 2 days each week 

    • minimise the amount of time spent in prolonged sitting 

    • break up long periods of sitting as often as possible. 

    Table C3: Definition of levels of physical activity

    Moderate intensity 

    Physical activity that requires some effort, but still allows the person to speak easily while undertaking the activity 

    Vigorous intensity 

    Physical activity that requires more effort and makes the person breathe harder and faster (“huff and puff”) 

    Source: ((DoH 2014)

    Levels of physical activity in Australia 

    Recent data specific to pregnant women are not available but results from national surveys give some indication of patterns of physical activity and sedentary behaviour.  

    In Australia in 2017-18 among 18-64 year olds (ABS 2019)

    • the majority (83.5%) engaged in some form of deliberate voluntary exercise (not including workplace physical activity) but only 15.0% of these participants met both the physical activity and muscle strengthening aspects of the guidelines 

    • more than half (55.4%) undertook 150 minutes or more of exercise in the last week, excluding workplace physical activity 

    • one quarter (24.9%) did strength or toning activities on two or more days in the last week as recommended in the guidelines 

    • more than two thirds (69.6%) did not conduct any strength or toning activities.  

    An Australian cross-sectional study found that fewer women participated in exercise during pregnancy (61%) compared to before pregnancy (87%) and that they exercised at a significantly lower frequency (p<0.05), intensity (p<0.05) and for a shorter time/duration (p<0.05) (Hayman et al 2016)

    Awareness of and barriers to physical activity among pregnant women 

    In a survey of regionally-based Australian women (n=142) (Hayman et al 2019), around half of women (53%) reported receiving advice on exercise as part of antenatal care. However, the advice given was frequently inconsistent with evidence–based guidelines concerning frequency, intensity, duration and benefits and harms. 

    Systematic reviews have found that barriers to participating in physical activity were: 

    • categorised as intrapersonal (pregnancy-related symptoms and limitations, time constraints, perceptions of already being active, lack of motivation and mother-child safety concerns), interpersonal (lack of advice and information and lack of social support) and environmental, organisational and policy barriers (adverse weather, lack of resources) (Coll et al 2017) 

    • predominantly intrapersonal barriers such as fatigue, lack of time and pregnancy discomforts, while enablers included maternal and fetal health benefits (intrapersonal), social support (interpersonal) and pregnancy-specific programs (Harrison et al 2018)

    11.3.2 Discussing physical activity 

    Guidelines on physical activity in pregnancy 

    The Evidence-based Physical Activity Guidelines for Pregnant Women recommend that (Brown et al 2020)

    • all women without contraindications be encouraged to meet the Australian Physical Activity and Sedentary Behaviour Guidelines (see above) before, during and after pregnancy 

    • modifications to physical activity/exercise may be required to accommodate the physical changes that occur as the pregnancy progresses — if there are any concerns (including warning signs and contraindications), women are advised to seek advice from a qualified health professional  

    • all pregnant women are advised to do pelvic floor exercises during and after pregnancy  

    • health professionals support women to take an active role in shared decision-making about their physical activity/exercise during and after pregnancy.  

    Recent evidence on the effects of physical activity during pregnancy 

    Physical fitness and quality of life 

    There is a possible increase in physical fitness associated with exercise in pregnancy (Hopkins et al 2010); (de Oliveria Melo et al 2012); (Halvorsen et al 2013); (Bisson et al 2015); (Guelfi et al 2016); (Seneviratne et al 2016); (Cai et al 2020) and rates of injury appear to be low (4.1 per 1,000 exercise hours; n=1,469). The evidence on the effect on quality of life suggests an improvement with physical activity (Montoya Arizabaleta et al 2010); (Gustafsson et al 2016); (Haakstad et al 2016); (Prabha et al 2019); (Rodriguez-Blanque et al 2020). Structured exercise interventions reduce the risk of antenatal (RR 0.44; 95%CI 0.32 to 0.61; 6 RCTs; n=798; moderate certainty) and postnatal (RR 0.47; 95%CI 0.34 to 0.65; 5 RCTs; n=1,613; moderate certainty) depression (Ramson et al 2020)

    Effect of physical activity on complications of pregnancy  

    The meta-analysis of RCTs conducted to inform the development of these Guidelines (Ramson et al 2020) found that structured exercise interventions during pregnancy were highly beneficial. The interventions mostly involved aerobic (treadmill, stationary cycling, walking, dance, circuit training, swimming) and muscle strengthening exercises (including pelvic floor exercises) for around 60 minutes, three times a week at an intensity of 60-80% of maximum heart rate or 12-14 on the Borg scale and continued to 36 to 39 weeks pregnancy. Compared to women who did not participate in the interventions, participants had lower mean gestational weight gain (MD 0.95 kg; 95%CI -1.20 to -0.69; 29 RCTs; n=5,680; moderate certainty) and were at lower risk of:  

    • weight gain exceeding US Institute of Medicine (IOM) recommendations (RR 0.77; 95%CI 0.69 to 0.87; 16 RCTs; n=4,333; low certainty) 

    • gestational diabetes (RR 0.74; 95%CI 0.60 to 0.90; 20 RCTs; n=5,592; low certainty) 

    • gestational hypertension (RR 0.51; 95%CI 0.37 to 0.71; 7 RCTs; n=3,060; moderate certainty) 

    • caesarean section (RR 0.85; 95%CI 0.74 to 0.98; 25 RCTs; n=5,704; moderate certainty)

    • macrosomia >4,000 g (RR 0.75; 95%CI 0.59 to 0.96; 15 RCTs; n=4,759; moderate certainty).

    Positive impact of physical activity on common conditions in pregnancy 

    • Incontinence: Pelvic floor muscle exercises appear to reduce the risk of urinary incontinence in late pregnancy (RR 0.38; 95%CI 0.20 to 0.72; 6 studies; n=624; low quality) and at 3-6 months postpartum (RR 0.71; 95%CI 0.54 to 0.95; 5 studies; n=673; moderate quality) but do not appear to affect the risk of faecal incontinence (RR 0.61; 95%CI 0.30 to 1.25; 2 studies; n=867; moderate quality) (Woodley et al 2017)

    • Glycaemic control: An acute bout of exercise is associated with a decrease in maternal blood glucose from before to during exercise (MD -0.94 mmol/L, 95%CI -1.18 to -0.70;6 studies, n=123) and following exercise (MD 0.57 mmol/L, 95% CI -0.72 to -0.41; n=333) (Davenport et al 2018)

    • Pelvic girdle and low back pain: There is evidence from systematic reviews (Shiri et al 2018); (Davenport et al 2019b), an RCT (Sklempe Kokic et al 2017) and a cohort study (Gjestland et al 2013) that physical activity during pregnancy is associated with a possible reduction in risk of low back (RR 0.91, 95%CI 0.83 to 0.99; 7 studies; n=1,175) and lumbopelvic pain (RR 0.96, 95%CI 0.90 to 1.02; 8 studies; n=1,737) and a reduction in severity of pain during pregnancy (SMD -1.03; 95%CI -1.58 to -0.48; 10 studies; very low to moderate certainty). The evidence on the effect of exercise on pelvic girdle pain and pain in the postpartum period is unclear.  

    • Sleep: It is unclear whether moderate to vigorous exercise during pregnancy improves sleep quality {{Loprinzi et al 2012; (Kocsis et al 2017); (Rodriguez-Blanque et al 2018); (Yang et al 2020) and it is not effective in treating insomnia in pregnancy (Yang et al 2020)

    Effect on labour 

    One systematic review (Kramer & McDonald 2006) and eleven RCTs (Salvesen & Morkved 2004); (Baciuk et al 2008); Barakat et al 2008}}; (Salvesen et al 2014); (Perales et al 2016a); (Perales et al 2016b); (Taniguchi & Sato 2016); (Barakat et al 2018); (Sanda et al 2018); (Rodriguez-Blanque et al 2019a); (Perales et al 2020) reported on duration of labour among women who had participated in a physical activity intervention during pregnancy and those who had not. The systematic review found no clear difference in length of the first (MD 2.00; 95%CI -1.15 to 5.15; 1 study; n=18) or second (MD 5.72; 95%CI -15.22 to 3.78; 1 study; n=18) stage of labour (Kramer & McDonald 2006). With some exceptions, (Salvesen et al 2014); (Perales et al 2016a); (Barakat et al 2018); (Rodriguez-Blanque et al 2019a); (Perales et al 2020), the RCTs found no clear difference in duration of any stage of labour. 

    Five RCTs ((Baciuk et al 2008); (Barakat et al 2009); (Salvesen et al 2014); (Taniguchi & Sato 2016); (Sanda et al 2018)) reported on pain relief during labour among women who had participated in a physical activity intervention during pregnancy and those who had not. One study reported fewer requests for analgesia in labour (RR 0.42; 95%CI 0.23 to 0.77; n=71) (Baciuk et al 2008) but there was no clear difference in the other studies. 

    Five RCTs (Salvesen & Morkved 2004); (Salvesen et al 2014); (Garnaes et al 2016); (Seneviratne et al 2016); (Rodriguez-Blanque et al 2019b) reported on perineal tears among women who had participated in a physical activity intervention during pregnancy and those who had not. One study found higher rates of intact perineum among the intervention group (aOR 8.57; 95% CI 1.85 to 39.68) (Rodriguez-Blanque et al 2019b) but there was no clear difference in rates of perineal tears in any other study. 

    Effect on the infant and child 

    There is evidence from systematic reviews that leisure-time exercise during pregnancy is not associated with congenital anomalies (OR 1.23, 95%CI 0.77 to 1.95; 14 studies; n=78,735; very low certainty) (Davenport et al 2019c) and appears to be protective against macrosomia (aOR 0.77; 95%CI 0.61 to 0.96; n=36,896) (Owe et al 2009) and low birthweight, with women who did not exercise before and during pregnancy having an increased risk of very low birthweight (OR 1.75; 95%CI 1.50 to 2.04; n=2,245) (Leiferman & Evenson 2003). Cohort studies suggest a positive association between physical activity during pregnancy and offspring neurodevelopment (4 studies) (Nino Cruz et al 2018). Physical activity during pregnancy does not appear to affect childhood weight (n=802) (Kong et al 2016)

    Safety of physical activity during pregnancy 

    The evidence did not support an association between: 

    • any exercise during pregnancy and: 
      • risk of miscarriage (OR 0.69; 95%CI 0.40 to 1.22; 10 studies) or perinatal mortality (OR 0.79; 95%CI 0.26 to 2.38; 6 studies) (Davenport et al 2019a) 
      • adverse impact on fetal heart rate or uteroplacental blood flow metrics (9 studies; 4,651 women) (Skow et al 2019) 
    • vigorous exercise during pregnancy and: 
      • risk of small for gestational age, low birthweight (Beetham et al 2019); (Hoffmann et al 2019), large for gestational age or high birthweight (Hoffmann et al 2019) 
      • risk of preterm birth with exercise in the first (OR 0.80; 95%CI 0.48 to 1.35) or second trimester (OR 0.52; 95%CI 0.24 to 1.11; n=1,699) (Evenson et al 2002) 

      • risk of preterm birth with vigorous activity up to 435 min/week (OR 1.2; 95%CI 0.5 to 3.1; n=1,647) (Jukic et al 2012) 

      • risk of post-term birth with exercise in the first (OR 0.93; 95%CI 0.45 to 1.89) or second (OR 1.15; 95%CI 0.47 to 2.79) trimester (n=1,699) (Evenson et al 2002) 

    • supine exercise and low birthweight (3 RCTs; very low to low certainty) (Mottola et al 2019)  
    • swimming or aqua aerobics and: 
      • risk of miscarriage <22 weeks (19-22 weeks HR 0.9; 95%CI 0.4 to 1.9; n=92,671) (Madsen et al 2007)  
      • risk of spina bifida (aOR 0.68; 95%CI 0.47 to 0.99; n=8,655) (Agopian et al 2013) 
      • significant increase in maternal body temperature (mean increase 0.16±0.35°C; n=109) (Brearley et al 2015)

    A systematic review noted that there was insufficient evidence to ascertain whether maternal exercise in the supine position is safe or should be avoided during pregnancy (Mottola et al 2019)

    Recommendation

    • Evidence-based
    • 11

    Advise women that usual physical activity during pregnancy has health benefits and is safe. 

    Approved by NHMRC in Nov 2020; expires Nov 2025 

    Further information about physical activity during pregnancy, including contraindications and signs and symptoms that suggest that physical activity/exercise should be modified, is included in Evidence-based Physical Activity Guidelines for Pregnant Women. 

    Recent evidence on the effects of occupational physical activity during pregnancy 

    The evidence on risks associated with occupational physical activity during pregnancy is unclear.  

    Heavy lifting (eg >200 kg/day) may be associated with an increased risk of pelvic pain (201-500 kg/day: aOR 1.45; 95%CI 1.31 to 1.60; n=50,143) (Larsen et al 2013), stillbirth among women with a previous fetal loss (201-975 kg per day: adjusted hazard ratio [aHR] 2.87; 95%CI 1.37 to 6.01; n=68,086) (Juhl et al 2013) and preterm birth among primigravid women (201-975 kg/day: aHR 1.43; 95%CI 1.13 to 1.80; n=65,530) (Mocevic et al 2014) but does not appear to be associated with small-for-gestational age (Pompeii et al 2005); (Snijder et al 2012); (Juhl et al 2014) or low birthweight ((Snijder et al 2012).  

    There is a possible association between occupational standing and increased risk of miscarriage (>6 hours a day: RR 1.16; 95%CI 1.01 to 1.32; 30 studies) or preterm birth (Ritsmitchai et al 1997) (>3 hours per day: OR 1.25; 95%CI 0.99 to 1.57; 11 studies) but no clear difference in small-for-gestational age, birthweight (Eunhee et al 2002) or pelvic pain (Juhl 2005).  

    There is insufficient evidence to draw conclusions on strenuous occupational physical exertion in pregnancy but it may be associated with preterm premature rupture of the membranes (OR 1.72; 95%CI 1.16 to 2.56; n=2,929) (Newman et al 2001) and pelvic pain (OR 1.47; 95%CI 1.17 to 1.84; n=2,758) (Juhl 2005)

    11.4 Lifestyle interventions 

    The literature review conducted to inform these Guidelines (Ramson et al 2020) analysed the results of randomised controlled trials that compared usual care to: 

    • dietary intervention: common themes in dietary advice provided included increasing consumption of fruit and vegetables, protein and fibre and reducing intake of saturated fats, carbohydrates and sugar (eg in soft drinks)  

    • exercise intervention: interventions mostly involved aerobic (treadmill, stationary cycling, walking, dance, circuit training, swimming) and muscle strengthening exercises (including pelvic floor exercises) for around 60 minutes, three times a week at an intensity of 60-80% of maximum heart rate or 12-14 on the Borg scale and continued to 36 to 39 weeks pregnancy 

    • lifestyle counselling intervention: most interventions involved counselling with a focus on gestational weight gain, diet and exercise with weight gain recommendations based on the US Institute of Medicine (IOM) guidelines and encouraged some form of self-monitoring (eg through weight gain charts, log books, pedometers).  

    Mean gestational weight gain was lower among women participating in a dietary intervention (MD -3.76 kg; 95%CI -6.38 to -1.13; 6 RCTs; n=1,432; very low certainty), exercise intervention (MD -0.95 kg; 95%CI -1.20 to -0.69; 29 RCTs; n=5,680; moderate certainty) or lifestyle counselling (MD -1.25 kg; 95%CI -1.64 to -0.86; 36 RCTs; n=9,083; low certainty). The risk of weight gain exceeding guidelines was also reduced by dietary intervention (RR 0.65; 95%CI 0.54 to 0.77; 4 RCTs; n=538; very low certainty), exercise intervention (RR 0.77; 95%CI 0.69 to 0.87; 16 RCTs; n=4,333; low certainty) and lifestyle counselling intervention (RR 0.83; 95%CI 0.78 to 0.89; 29 RCTs; n=7,905; low certainty). The risk of postnatal weight retention was reduced with lifestyle counselling (MD -1.19 kg; 95%CI -1.62 to -0.76; 11 RCTs; n=2,483; moderate certainty). There was no clear difference in postnatal weight retention with a dietary intervention (MD -0.55 kg; 95%CI -2.02 to 0.92; 2 RCTs; n=556; very low certainty) or exercise intervention (MD –0.20 kg; 95%CI –1.48 to 1.09; 5 RCTs; n=388; moderate certainty). 

    Risk of gestational diabetes was reduced by exercise interventions (RR 0.74; 95%CI 0.60 to 0.90; 20 RCTs; n=5,592; low certainty), probably reduced by lifestyle counselling (RR 0.90; 95%CI 0.81 to 1.01; 26 RCTs; n=9,011; moderate certainty) with no differences seen with dietary interventions (RR 0.86; 95%CI 0.64 to 1.17; 6 RCTs; n=1,424; very low certainty).  

    There was a reduced risk of gestational hypertension with dietary intervention (RR 0.29; 95%CI 0.13 to 0.61; 3 RCTs; n=429; moderate certainty) or exercise intervention (RR 0.51; 95%CI 0.37 to 0.71; 7 RCTs; n=3,060; moderate certainty) but not with lifestyle counselling (RR 0.99; 95%CI 0.77 to 1.28; 13 RCTs; n=4,890; low certainty). No difference in risk of pre-eclampsia was seen with any type of intervention (low to moderate certainty). 

    Risk of caesarean section was reduced with exercise intervention (RR 0.85; 95%CI 0.74 to 0.98; 25 RCTs; n=5,704; moderate certainty) and probably reduced with lifestyle counselling (RR 0.95; 95%CI 0.89 to 1.02; 25 RCTs; n=9,049; low certainty). There was no difference in risk of caesarean section with a dietary intervention (RR 0.85; 95%CI 0.64 to 1.11; 6 RCTs; n=1,461; very low certainty). 

    The risk of antenatal depression was reduced with exercise intervention (RR 0.44; 95%CI 0.32 to 0.61; 6 RCTs; n=798; moderate certainty) but not lifestyle counselling (RR 0.99; 95%CI 0.80 to 1.22; 2 RCTs; n=2,908; low certainty). The risk of postnatal depression was reduced with exercise intervention (RR 0.47; 95%CI 0.34 to 0.65; 5 RCTs; n=1,613; moderate certainty). 

    The risk of preterm birth was reduced with a dietary intervention (RR 0.43; 95%CI 0.24 to 0.79; 4 RCTs; n=1,296; moderate certainty), probably reduced with lifestyle counselling (RR 0.85; 95%CI 0.72 to 1.01; 18 RCTs; n=7,497; moderate certainty) but not changed by exercise intervention (RR 0.95; 95%CI 0.74 to 1.22; 15 RCTs; n=4,388; moderate certainty).  

    No difference was seen in risk of macrosomia >4,000g with dietary intervention (RR 0.97; 95%CI 0.84 to 1.11; 3 RCTs; n=1,138; very low certainty) but there was a reduction with exercise intervention (RR 0.75; 95%CI 0.59 to 0.96; 15 RCTs; n=4,759; moderate certainty) and a probable reduction with lifestyle counselling (RR 0.91; 95%CI 0.82 to 1.01; 17 RCTs; n=7,664; low certainty). There was also a reduction of risk of macrosomia >4,500 g with lifestyle counselling (RR 0.67; 95%CI 0.46 to 0.97; 5 RCTs; n=3,435; moderate certainty). There was no difference seen in risk of low birthweight with an exercise intervention (RR 0.94; 95%CI 0.68 to 1.28; 11 RCTs; n=3,247; moderate certainty) or lifestyle counselling (RR 0.87; 95%CI 0.65 to 1.17; 4 RCTs; n=3,665; low certainty). There was a possible reduction in risk of large-for-gestational age with lifestyle counselling (RR 0.89; 95%CI 0.79 to 1.00; 22 RCTs; n=8,455; moderate certainty) but no clear difference in risk with the other interventions. 

    There was no clear difference in risk of small-for-gestational age, Apgar score <7 at 5 minutes or weight in early childhood with any intervention. 

    An Australian study found that antenatal lifestyle interventions for preventing gestational diabetes and hypertensive diseases of pregnancy are likely to be cost effective (Bailey et al 2020). Studies from overseas found that lifestyle interventions were cost-effective for gestational weight gain (Broekhuizen et al 2018) but not blood glucose levels, insulin resistance (Oostdam et al 2012); (Broekhuizen et al 2018) or infant weight (Oostdam et al 2012), were inconsistent regarding quality-adjusted life years (Oostdam et al 2012); (Broekhuizen et al 2018) and a better understanding of the short- and long-term costs of large for gestational age and weight gain exceeding IOM recommendations is necessary (O'Sullivan et al 2020)

    Recommendation

    • Consensus-based
    • VI

    At every antenatal visit, give women advice on the benefits of a healthy diet and regular physical activity in preventing adverse outcomes, including excessive weight gain. 

    Approved by NHMRC in Nov 2020; expires Nov 2025 

    Recommendation

    • Evidence-based
    • 12

    Advise women that structured lifestyle interventions improve maternal and infant outcomes and are effective in preventing excessive weight gain. 

    Approved by NHMRC in Nov 2020; expires Nov 2025 

    11.5 Practice summary: nutrition and physical activity

    Nutrition

    When: All antenatal visits

    Who: Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander Health Practitioner; Aboriginal and Torres Strait Islander Health Worker; multicultural health worker; accredited dietitian; nutritionist

    • Assess levels of nutrition:
      Ask women about their current eating patterns.
    • Promote healthy eating:
      Explain the benefits of healthy nutrition for the mother and baby. Give examples of healthy dietary patterns, including ‘eating a rainbow’ (ie eating fruits and vegetables of different colours to promote adequate vitamin and mineral consumption).
    • Discuss foods to avoid:
      Give examples of foods that can cause harm during pregnancy, including alcohol, sources of listeria and fish high in mercury (see Table C2).
    • Discuss use of nutritional supplements:
      Explain that some supplements (folic acid, iodine) are recommended for all women during some stages of pregnancy, while others may be harmful at levels higher than the recommended daily intake.
    • Consider referral:
      Referral to an accredited practising dietitian may be a consideration if there is concern about the quality of nutritional intake, the woman would like information about nutrition for herself and her family, clinical assessment confirms that the women is underweight, overweight or obese or there are other factors of concern (eg diabetes, gastrointestinal disorders). An accredited practicing dietitian may also need to be consulted if the woman is under 18 years of age due to increased dietary need; most guidelines are based on adult needs.
    • Take a holistic approach:
      Tailor dietary advice to the individual woman. Consider the availability and affordability of foods appropriate to the woman’s cultural practices and preferences and the need for and affordability of supplements.

    Physical activity

    When: All antenatal visits.

    Who: Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander Health Practitioner; Aboriginal and Torres Strait Islander Health Worker; multicultural health worker; physiotherapist, accredited exercise physiologist or accredited exercise scientist

    • Assess levels of activity:
      Ask women about their current levels of physical activity, including the frequency, intensity, duration and type of activity.
    • Promote healthy levels of physical activity
      Give women advice based on the Australian Physical Activity and Sedentary Behaviour Guidelines and explain that physical activity during pregnancy has health benefits and is safe.
    • Provide information
      Give information about local supports for physical activity (eg women’s walking groups, swimming clubs). Advise women to avoid exercising in the heat of the day and to drink plenty of water when active.
    • Consider referral:
      Referral to an accredited exercise physiologist may be a consideration if there is a concern about the safety of physical activity for the woman and her family or the woman has not been physically active prior to pregnancy, clinical assessment confirms underweight or overweight of the woman or there are other factors of concern (e.g. diabetes, musculoskeletal conditions).
    • Take a holistic approach
      Assist women to identify ways of being physically active that are appropriate to their cultural beliefs and practices (eg activities they can do at home)

    11.6 Resources

    11.6.1 Nutrition

    11.6.2 Physical activity

    References

    • Abraha I, Bonacini MI, Montedori A et al (2019) Oral iron-based interventions for prevention of critical outcomes in pregnancy and postnatal care: An overview and update of systematic reviews. J Evid Based Med 12(2): 155-66.
    • Abramovici A, Gandley RE, Clifton RG et al (2015) Prenatal vitamin C and E supplementation in smokers is associated with reduced placental abruption and preterm birth: a secondary analysis. BJOG 122(13): 1740-7.
    • ABS (2019) National Health Survey: First Results, 2017-18. Canberra: Australian Bureau of Statistics.
    • Agopian AJ, Lupo PJ, Canfield MA et al (2013) Swimming pool use and birth defect risk. American Journal of Obstetrics and Gynecology 209(3): 219.e1-19.e9.
    • AIHW (2016) Monitoring the health impacts of mandatory folic acid and iodine fortification. Cat. no. PHE 208. Canberra: Australian Institute of Health and Welfare.
    • Alvarez Zallo N, Aguinaga-Ontoso I, Alvarez-Alvarez I et al (2018) Influence of the Mediterranean diet during pregnancy in the development of wheezing and eczema in infants in Pamplona, Spain. Allergol Immunopathol (Madr) 46(1): 9-14.
    • Alvarez Zallo N, Aguinaga-Ontoso I, Alvarez-Alvarez I et al (2018) Influence of the Mediterranean diet during pregnancy in the development of wheezing and eczema in infants in Pamplona, Spain. Allergol Immunopathol (Madr) 46(1): 9-14.
    • Assaf-Balut C, Garcia de la Torre N, Duran A et al (2017)A Mediterranean diet with additional extra virgin olive oil and pistachios reduces the incidence of gestational diabetes mellitus (GDM): A randomized controlled trial: The St. Carlos GDM prevention study. PLoS One 12(10): e0185873.
    • Assaf-Balut C, Garcia de la Torre N, Fuentes M et al (2018) A high adherence to six food targets of the Mediterranean diet in the late first trimester is associated with a reduction in the risk of materno-foetal outcomes: The St. Carlos Gestational Diabetes Mellitus Prevention Study. Nutrients 11(1).
    • Assaf-Balut C, Garcia de la Torre N, Duran A et al (2019) A Mediterranean diet with an enhanced consumption of extra virgin olive oil and pistachios improves pregnancy outcomes in women without gestational diabetes mellitus: a sub-analysis of the St. Carlos Gestational Diabetes Mellitus Prevention Study. Ann Nutr Metab 74(1): 69-79.
    • Azad MB, Sharma AK, de Souza RJ et al (2016) Association between artificially sweetened beverage consumption during pregnancy and infant body mass index. JAMA Pediatr 170(7): 662-70.
    • Baciuk EP, Pereira RI, Cecatti JG et al (2008) Water aerobics in pregnancy: Cardiovascular response, labor and neonatal outcomes. Reprod Health 5: 10.
    • Bailey C, Skouteris H, Harrison CL et al (2020) Cost Effectiveness of Antenatal Lifestyle Interventions for Preventing Gestational Diabetes and Hypertensive Disease in Pregnancy. Pharmacoecon Open.
    • Ball K, Timperio A, Crawford D (2009) Neighbourhood socioeconomic inequalities in food access and affordability. Health & place 15(2): 578–85.
    • Balogun OO, da Silva Lopes K, Ota E et al (2016) Vitamin supplementation for preventing miscarriage. Cochrane Database Syst Rev(5): CD004073.
    • Barakat R, Stirling JR, Lucia A (2008) Does exercise training during pregnancy affect gestational age? A randomised controlled trial. Br J Sports Med 42(8): 674-8.
    • Barakat R, Ruiz JR, Stirling JR et al (2009) Type of delivery is not affected by light resistance and toning exercise training during pregnancy: a randomized controlled trial. Am J Obstet Gynecol201(6): 590 e1-6.
    • Barakat R, Franco E, Perales M et al (2018) Exercise during pregnancy is associated with a shorter duration of labor. A randomized clinical trial. Eur J Obstet Gynecol Reprod Biol 224: 33-40.
    • Baskin R, Hill B, Jacka FN et al (2017) Antenatal dietary patterns and depressive symptoms during pregnancy and early post-partum. Matern Child Nutr 13(1).
    • Bedard A, Northstone K, Henderson AJ et al (2017) Maternal intake of sugar during pregnancy and childhood respiratory and atopic outcomes. Eur Respir J 50(1).
    • Beetham KS, Giles C, Noetel M et al (2019) The effects of vigorous intensity exercise in the third trimester of pregnancy: a systematic review and meta-analysis. BMC Pregnancy Childbirth 19(1): 281.
    • Bisson M, Almeras N, Dufresne SS et al (2015) A 12-Week Exercise Program for Pregnant Women with Obesity to Improve Physical Activity Levels: An Open Randomised Preliminary Study. PLoS One 10(9): e0137742.
    • Bookari K, Yeatman H, Williamson M (2016) Australian pregnant women's awareness of gestational weight gain and dietary guidelines: opportunity for action. J Pregnancy 2016: 8162645.
    • Bookari K, Yeatman H, Williamson M (2017) Falling short of dietary guidelines - What do Australian pregnant women really know? A cross sectional study. Women Birth 30(1): 9-17.
    • Brearley AL, Sherburn M, Galea MP et al (2015) Pregnant women maintain body temperatures within safe limits during moderate-intensity aqua-aerobic classes conducted in pools heated up to 33 degrees Celsius: an observational study. Journal of Physiotherapy 61(4): 199-203.
    • Broekhuizen K, Simmons D, Devlieger R et al (2018) Cost-effectiveness of healthy eating and/or physical activity promotion in pregnant women at increased risk of gestational diabetes mellitus: economic evaluation alongside the DALI study, a European multicenter randomized controlled trial. International Journal of Behavioral Nutrition and Physical Activity 15(1).
    • Brown WJ, Hayman M, Haakstad LAH et al (2020) Evidence-based physical activity guidelines for pregnant women. Canberra: Report for the Australian Government Department of Health. Available at:
    • Bryant J, Waller A, Cameron E et al (2017) Diet during pregnancy: Women's knowledge of and adherence to food safety guidelines. Aust N Z J Obstet Gynaecol 57(3): 315-22.
    • Bulloch RE, Lovell AL, Jordan VMB et al (2018) Maternal folic acid supplementation for the prevention of preeclampsia: A systematic review and meta-analysis. Paediatric and Perinatal Epidemiology 32(4): 346-57.
    • Bunyavanich S, Rifas-Shiman SL, Platts-Mills TA et al (2014) Peanut, milk, and wheat intake during pregnancy is associated with reduced allergy and asthma in children. J Allergy Clin Immunol 133(5): 1373-82.
    • Buppasiri P, Lumbiganon P, Thinkhamrop J et al (2015) Calcium supplementation (other than for preventing or treating hypertension) for improving pregnancy and infant outcomes. Cochrane Database Syst Rev(2): CD007079.
    • Burns C & Inglis A (2007) Measuring food access in Melbourne: access to healthy and fast foods by car, bus and foot in an urban municipality in Melbourne. Health & Place 13(4): 877–85.
    • Cai C, Ruchat SM, Sivak A et al (2020) Prenatal exercise and cardiorespiratory health and fitness: A meta-analysis. Med Sci Sports Exerc.
    • Castro-Rodriguez JA, Ramirez-Hernandez M, Padilla O et al (2016) Effect of foods and Mediterranean diet during pregnancy and first years of life on wheezing, rhinitis and dermatitis in preschoolers. Allergol Immunopathol (Madr) 44(5): 400-9.
    • Censi S, Watutantrige-Fernando S, Groccia G et al (2019) The effects of iodine supplementation in pregnancy on iodine status, thyroglobulin levels and thyroid function parameters: results from a randomized controlled clinical trial in a mild-to-moderate iodine deficiency area. Nutrients 11(11).
    • Chatterjee R, Shand A, Nassar N et al (2016) Iron supplement use in pregnancy - Are the right women taking the right amount? Clin Nutr 35(3): 741-7.
    • Chatzi L, Rifas-Shiman SL, Georgiou V et al (2017) Adherence to the Mediterranean diet during pregnancy and offspring adiposity and cardiometabolic traits in childhood. Pediatr Obes 12 Suppl 1: 47-56.
    • Chawanpaiboon S (2019) A randomized controlled trial of the correlation between iodine supplementation in pregnancy and maternal urine iodine and neonatal thyroid stimulating hormone levels. Siriraj Medical Journal 71(1).
    • Chen LW, Tint MT, Fortier MV et al (2016) Maternal macronutrient intake during pregnancy is associated with neonatal abdominal adiposity: The Growing Up in Singapore Towards healthy Outcomes (GUSTO) study. J Nutr 146(8): 1571-9.
    • Chia A-R, de Seymour JV, Colega M et al (2016) A vegetable, fruit, and white rice dietary pattern during pregnancy is associated with a lower risk of preterm birth and larger birth size in a multiethnic Asian cohort: the Growing Up in Singapore Towards healthy Outcomes (GUSTO) cohort study. The American Journal of Clinical Nutrition 104(5): 1416-23.
    • Chia AR, Tint MT, Han CY et al (2018) Adherence to a healthy eating index for pregnant women is associated with lower neonatal adiposity in a multiethnic Asian cohort: the Growing Up in Singapore Towards healthy Outcomes (GUSTO) Study. Am J Clin Nutr 107(1): 71-79.
    • Chia AR, Chen LW, Lai JS et al (2019) Maternal dietary patterns and birth outcomes: a systematic review and meta-analysis. Adv Nutr 10(4): 685-95.
    • Chiavarini M, Naldini G, Fabiani R (2018) Maternal Folate Intake and Risk of Childhood Brain and Spinal Cord Tumors: A Systematic Review and Meta-Analysis. Neuroepidemiology 51(1-2): 82-95.
    • Coll CV, Domingues MR, Goncalves H et al (2017) Perceived barriers to leisure-time physical activity during pregnancy: A literature review of quantitative and qualitative evidence. J Sci Med Sport 20(1): 17-25.
    • Condo D, Huyhn D, Anderson AJ et al (2017) Iodine status of pregnant women in South Australia after mandatory iodine fortification of bread and the recommendation for iodine supplementation. Matern Child Nutr 13(4).
    • Davenport MH, Sobierajski F, Mottola MF et al (2018) Glucose responses to acute and chronic exercise during pregnancy: a systematic review and meta-analysis. Br J Sports Med 52(21): 1357-66.
    • Davenport MH, Kathol AJ, Mottola MF et al (2019a) Prenatal exercise is not associated with fetal mortality: a systematic review and meta-analysis. Br J Sports Med 53(2): 108-15.
    • Davenport MH, Marchand AA, Mottola MF et al (2019b) Exercise for the prevention and treatment of low back, pelvic girdle and lumbopelvic pain during pregnancy: a systematic review and meta-analysis. Br J Sports Med 53(2): 90-98.
    • Davenport MH, Yoo C, Mottola MF et al (2019c) Effects of prenatal exercise on incidence of congenial anomalies and hyperthermia: a systematic review and meta-analysis. Br J Sports Med 53(2): 116-23.
    • de Oliveria Melo AS, Silva JL, Tavares JS et al (2012) Effect of a physical exercise program during pregnancy on uteroplacental and fetal blood flow and fetal growth: a randomized controlled trial. Obstet Gynecol 120(2 Pt 1): 302-10.
    • De-Regil LM, Pena-Rosas JP, Fernandez-Gaxiola AC et al (2015) Effects and safety of periconceptional oral folate supplementation for preventing birth defects. Cochrane Database Syst Rev(12): CD007950.
    • Deligiannidis KM, Byatt N, Freeman MP (2014) Pharmacotherapy for mood disorders in pregnancy: a review of pharmacokinetic changes and clinical recommendations for therapeutic drug monitoring. J Clin Psychopharmacol 34(2): 244-55.
    • Dessypris N, Karalexi MA, Ntouvelis E et al (2017) Association of maternal and index child's diet with subsequent leukemia risk: A systematic review and meta analysis. Cancer Epidemiol 47: 64-75.
    • DoH (2014) Australian Physical Activity and Sedentary Behaviour Guidelines. Canberra: Australian Government Department of Health.
    • Dominguez LJ, Martinez-Gonzalez MA, Basterra-Gortari FJ et al (2014) Fast food consumption and gestational diabetes incidence in the SUN project. PLoS One 9(9): e106627.
    • Donazar-Ezcurra M, Lopez-Del Burgo C, Martinez-Gonzalez MA et al (2018) Soft drink consumption and gestational diabetes risk in the SUN project. Clin Nutr 37(2): 638-45.
    • Duke CH, Williamson JA, Snook KR et al (2017) Association between fruit and vegetable consumption and sleep quantity in pregnant women. Matern Child Health J 21(5): 966-73.
    • Emmett PM, Jones LR, Golding J (2015) Pregnancy diet and associated outcomes in the Avon Longitudinal Study of Parents and Children. Nutr Rev 73 Suppl 3: 154-74.
    • Emond JA, Karagas MR, Baker ER et al (2018) Better diet quality during pregnancy is associated with a reduced likelihood of an infant born small for gestational age: an analysis of the prospective New Hampshire Birth Cohort Study. J Nutr 148(1): 22-30.
    • Englund-Ogge L, Brantsaeter AL, Sengpiel V et al (2014) Maternal dietary patterns and preterm delivery: results from large prospective cohort study. BMJ 348: g1446.
    • Englund-Ogge L, Brantsaeter AL, Juodakis J et al (2019) Associations between maternal dietary patterns and infant birth weight, small and large for gestational age in the Norwegian Mother and Child Cohort Study. Eur J Clin Nutr 73(9): 1270-82.
    • Eunhee H, Cho S-I, Park H et al (2002) Does standing at work during pregnancy result in reduced infant birth weight? JOEM 44(9): 815-21.
    • Evenson KR, Siega-Riz AM, Savitz DA et al (2002) Vigorous leisure activity and pregnancy outcome. Epidemiology 13(6): 653-9.
    • Farebrother J, Naude CE, Nicol L et al (2018) Effects of Iodized Salt and Iodine Supplements on Prenatal and Postnatal Growth: A Systematic Review. Adv Nutr 9(3): 219-37.
    • Feng Y, Wang S, Chen R et al (2015) Maternal folic acid supplementation and the risk of congenital heart defects in offspring: a meta-analysis of epidemiological observational studies. Sci Rep 5: 8506.
    • Fernandez-Barres S, Romaguera D, Valvi D et al (2016) Mediterranean dietary pattern in pregnant women and offspring risk of overweight and abdominal obesity in early childhood: the INMA birth cohort study. Pediatr Obes 11(6): 491-99.
    • Fernandez-Barres S, Vrijheid M, Manzano-Salgado CB et al (2019) The association of mediterranean diet during pregnancy with longitudinal body mass index trajectories and cardiometabolic risk in early childhood. J Pediatr 206: 119-27 e6.
    • Flynn AC, Seed PT, Patel N et al (2016) Dietary patterns in obese pregnant women; influence of a behavioral intervention of diet and physical activity in the UPBEAT randomized controlled trial. Int J Behav Nutr Phys Act 13(1): 124.
    • Foster M, Herulah UN, Prasad A et al (2015) Zinc Status of Vegetarians during Pregnancy: A Systematic Review of Observational Studies and Meta-Analysis of Zinc Intake. Nutrients 7(6): 4512-25.
    • Frawley J, Adams J, Steel A et al (2015) Women's use and self-prescription of herbal medicine during pregnancy: An examination of 1,835 pregnant women. Womens Health Issues 25(4): 396-402.
    • Frawley J, Sibbritt D, Broom A et al (2016) Women's attitudes towards the use of complementary and alternative medicine products during pregnancy. J Obstet Gynaecol 36(4): 462-7.
    • Frazier AL, Camargo CA, Jr., Malspeis S et al (2014) Prospective study of peripregnancy consumption of peanuts or tree nuts by mothers and the risk of peanut or tree nut allergy in their offspring. JAMA Pediatr 168(2): 156-62.
    • FSANZ (2019) Caffeine. Accessed: 13 April 2020.
    • Fu ZM, Ma ZZ, Liu GJ et al (2018) Vitamins supplementation affects the onset of preeclampsia. J Formos Med Assoc 117(1): 6-13.
    • Garnaes KK, Morkved S, Salvesen O et al (2016) Exercise Training and Weight Gain in Obese Pregnant Women: A Randomized Controlled Trial (ETIP Trial). PLoS Med 13(7): e1002079.
    • Gjestland K, Bo K, Owe KM et al (2013) Do pregnant women follow exercise guidelines? Prevalence data among 3482 women, and prediction of low-back pain, pelvic girdle pain and depression. Br J Sports Med 47(8): 515-20.
    • Glazier JD, Hayes DJL, Hussain S et al (2018) The effect of Ramadan fasting during pregnancy on perinatal outcomes: a systematic review and meta-analysis. BMC Pregnancy Childbirth 18(1): 421.
    • Gowachirapant S, Jaiswal N, Melse-Boonstra A et al (2017) Effect of iodine supplementation in pregnant women on child neurodevelopment: a randomised, double-blind, placebo-controlled trial. The Lancet Diabetes & Endocrinology 5(11): 853-63.
    • Greenop KR, Miller M, Attia J et al (2014) Maternal consumption of coffee and tea during pregnancy and risk of childhood brain tumors: results from an Australian case-control study. Cancer Causes Control 25(10): 1321-7.
    • Gresham E, Collins CE, Mishra GD et al (2016) Diet quality before or during pregnancy and the relationship with pregnancy and birth outcomes: the Australian Longitudinal Study on Women's Health. Public Health Nutr 19(16): 2975-83.
    • Guelfi KJ, Ong MJ, Crisp NA et al (2016) Regular Exercise to Prevent the Recurrence of Gestational Diabetes Mellitus: A Randomized Controlled Trial. Obstet Gynecol 128(4): 819-27.
    • Guess K, Malek L, Anderson A et al (2017) Knowledge and practices regarding iodine supplementation: A national survey of healthcare providers. Women Birth 30(1): e56-e60.
    • Gustafsson MK, Stafne SN, Romundstad PR et al (2016) The effects of an exercise programme during pregnancy on health-related quality of life in pregnant women: a Norwegian randomised controlled trial. BJOG 123(7): 1152-60.
    • Haakstad LA, Torset B, Bo K (2016) What is the effect of regular group exercise on maternal psychological outcomes and common pregnancy complaints? An assessor blinded RCT. Midwifery 32: 81-6.
    • Halvorsen S, Haakstad LA, Edvardsen E et al (2013) Effect of aerobic dance on cardiorespiratory fitness in pregnant women: a randomised controlled trial. Physiotherapy 99(1): 42-8.
    • Harding KB, Pena-Rosas JP, Webster AC et al (2017) Iodine supplementation for women during the preconception, pregnancy and postpartum period. Cochrane Database Syst Rev 3: CD011761.
    • Harrison AL, Taylor NF, Shields N et al (2018) Attitudes, barriers and enablers to physical activity in pregnant women: a systematic review. J Physiother 64(1): 24-32.
    • Harrison M, Lee A, Findlay M et al (2010) The increasing cost of healthy food. Aust N Z J Public Health 34(2): 179–86.
    • Hayman M, Short C, Reaburn P (2016) An investigation into the exercise behaviours of regionally based Australian pregnant women. J Sci Med Sport 19(8): 664-8.
    • Hayman M, Reaburn P, Alley S et al (2019) What exercise advice are women receiving from their healthcare practitioners during pregnancy? Women Birth.
    • Hine T, Zhao Y, Begley A et al (2018) Iodine-containing supplement use by pregnant women attending antenatal clinics in Western Australia. Aust N Z J Obstet Gynaecol 58(6): 636-42.
    • Hoffmann J, Gunther J, Geyer K et al (2019) Associations between prenatal physical activity and neonatal and obstetric outcomes-a secondary analysis of the cluster-randomized GeliS trial. J Clin Med 8(10).
    • Hofmeyr GJ, Belizan JM, von Dadelszen P et al (2014) Low-dose calcium supplementation for preventing pre-eclampsia: a systematic review and commentary. BJOG 121(8): 951-7.
    • Hofmeyr GJ, Lawrie TA, Atallah ÁN et al (2018) Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database of Systematic Reviews.
    • Holst L, Havnen GC, Nordeng H (2014) Echinacea and elderberry-should they be used against upper respiratory tract infections during pregnancy? Front Pharmacol 5: 31.
    • Hopkins SA, Baldi JC, Cutfield WS et al (2010) Exercise training in pregnancy reduces offspring size without changes in maternal insulin sensitivity. J Clin Endocrinol Metab 95(5): 2080-8.
    • Hua X, Zhang J, Guo Y et al (2016) Effect of folic acid supplementation during pregnancy on gestational hypertension/preeclampsia: A systematic review and meta-analysis. Hypertens Pregnancy 35(4): 447-60.
    • Hurley S, Eastman CJ, Gallego G (2019) The impact of mandatory iodine fortification and supplementation on pregnant and lactating women in Australia. Asia Pac J Clin Nutr 28(1): 15-22.
    • Hynes KL, Seal JA, Otahal P et al (2019) Women remain at risk of iodine deficiency during pregnancy: The importance of iodine supplementation before conception and throughout gestation. Nutrients 11(1).
    • Ikem E, Halldorsson TI, Birgisdóttir BE et al (2019) Dietary patterns and the risk of pregnancy-associated hypertension in the Danish National Birth Cohort: a prospective longitudinal study. BJOG 126(5): 663-73.
    • Jahanfar S & Jaafar SH (2015) Effects of restricted caffeine intake by mother on fetal, neonatal and pregnancy outcomes. Cochrane Database Syst Rev(6): CD006965.
    • Jayasinghe C, Polson R, van Woerden HC et al (2018) The effect of universal maternal antenatal iron supplementation on neurodevelopment in offspring: a systematic review and meta-analysis. BMC Pediatr 18(1): 150.
    • Juhl M (2005) Psychosocial and physical work environment, and risk of pelvic pain in pregnancy. A study within the Danish national birth cohort. J Epidemiol & Community Health 59(7): 580-85.
    • Juhl M, Strandberg-Larsen K, Larsen PS et al (2013) Occupational lifting during pregnancy and risk of fetal death in a large national cohort study. Scand J Work Environ Health 39(4): 335-42.
    • Juhl M, Larsen PS, Andersen PK et al (2014) Occupational lifting during pregnancy and child’s birth size in a large cohort study. Scand J Work Environ Health 40(4): 411-19.
    • Jukic AM, Evenson KR, Daniels JL et al (2012) A prospective study of the association between vigorous physical activity during pregnancy and length of gestation and birthweight. Matern Child Health J 16(5): 1031-44.
    • Keats EC, Haider BA, Tam E et al (2019) Multiple-micronutrient supplementation for women during pregnancy. Cochrane Database Syst Rev 3: CD004905.
    • Khaing W, Vallibhakara SA, Tantrakul V et al (2017) Calcium and Vitamin D Supplementation for Prevention of Preeclampsia: A Systematic Review and Network Meta-Analysis. Nutrients 9(10).
    • Kocsis I, Szilágyi T, Turos J et al (2017) Effect of a gymnastics program on sleep characteristics in pregnant women. Taiwanese Journal of Obstetrics and Gynecology 56(2): 204-09.
    • Kong KL, Gillman MW, Rifas-Shiman SL et al (2016) Leisure time physical activity before and during mid-pregnancy and offspring adiposity in mid-childhood. Pediatr Obes 11(2): 81-7.
    • Kramer MS & McDonald SW (2006) Aerobic exercise for women during pregnancy. Cochrane Database of Systematic Reviews.
    • Landrigan T & Pollard C (2011) Food Access and Cost Survey (FACS), Western Australia, 2010. Perth: Department of Health, WA.
    • Larsen PS, Strandberg-Larsen K, Juhl M et al (2013) Occupational lifting and pelvic pain during pregnancy: a study within the Danish National Birth Cohort. Scand J Work Environ Health 39(1): 88-95.
    • Lassi ZS, Salam RA, Haider BA et al (2013) Folic acid supplementation during pregnancy for maternal health and pregnancy outcomes. Cochrane Database of Systematic Reviews.
    • Lee A, Belski R, Radcliffe J et al (2016) What do pregnant women know about the healthy eating guidelines for pregnancy? A web-based questionnaire. Matern Child Health J 20(10): 2179-88.
    • Lee A, Muggli E, Halliday J et al (2018a) What do pregnant women eat, and are they meeting the recommended dietary requirements for pregnancy? Midwifery 67: 70-76.
    • Lee A, Newton M, Radcliffe J et al (2018b) Pregnancy nutrition knowledge and experiences of pregnant women and antenatal care clinicians: A mixed methods approach. Women Birth 31(4): 269-77.
    • Lee A & Ride K (2018) Review of nutrition among Aboriginal and Torres Strait Islander people. Australian Indigenous Health Bulletin 18(1).
    • Lee YQ, Collins CE, Schumacher TL et al (2018c) Disparities exist between the dietary intake of Indigenous Australian women during pregnancy and the Australian dietary guidelines: the Gomeroi gaaynggal study. J Hum Nutr Diet 31(4): 473-85.
    • Leermakers ETM, Tielemans MJ, van den Broek M et al (2017) Maternal dietary patterns during pregnancy and offspring cardiometabolic health at age 6 years: The generation R study. Clin Nutr 36(2): 477-84.
    • Leiferman JA & Evenson KR (2003) The effect of regular leisure physical activity on birth outcomes. Matern Child Health J 7(1): 59-64.
    • Leonard D, Buttner P, Thompson F et al (2018) Anaemia in pregnancy among Aboriginal and Torres Strait Islander women of Far North Queensland: A retrospective cohort study. Nutr Diet 75(5): 457-67.
    • Liu C, Liu C, Wang Q et al (2018a) Supplementation of folic acid in pregnancy and the risk of preeclampsia and gestational hypertension: a meta-analysis. Archives of Gynecology and Obstetrics 298(4): 697-704.
    • Liu E, Pimpin L, Shulkin M et al (2018b) Effect of Zinc Supplementation on Growth Outcomes in Children under 5 Years of Age. Nutrients 10(3).
    • Livock M, Anderson PJ, Lewis S et al (2017) Maternal micronutrient consumption periconceptionally and during pregnancy: a prospective cohort study. Public Health Nutr 20(2): 294-304.
    • Lombardi C, Ganguly A, Bunin GR et al (2015) Maternal diet during pregnancy and unilateral retinoblastoma. Cancer Causes Control 26(3): 387-97.
    • Loprinzi PD, Loprinzi KL, Cardinal BJ (2012) The relationship between physical activity and sleep among pregnant women. Mental Health and Physical Activity 5(1): 22-27.
    • Madsen M, Jorgensen T, Jensen ML et al (2007) Leisure time physical exercise during pregnancy and the risk of miscarriage: a study within the Danish National Birth Cohort. BJOG 114(11): 1419-26.
    • Makrides M, Crosby DD, Shepherd E et al (2014) Magnesium supplementation in pregnancy. Cochrane Database of Systematic Reviews.
    • Makrides M, Best K, Yelland L et al (2019) A Randomized Trial of Prenatal n−3 Fatty Acid Supplementation and Preterm Delivery. New England Journal of Medicine 381(11): 1035-45.
    • Malek L, Umberger W, Makrides M et al (2016a) Poor adherence to folic acid and iodine supplement recommendations in preconception and pregnancy: a cross-sectional analysis. Australian and New Zealand Journal of Public Health 40(5): 424-29.
    • Malek L, Umberger W, Makrides M et al (2016b) Adherence to the Australian dietary guidelines during pregnancy: evidence from a national study. Public Health Nutr 19(7): 1155-63.
    • Malek L, Umberger WJ, Makrides M et al (2018) Understanding motivations for dietary supplementation during pregnancy: A focus group study. Midwifery 57: 59-68.
    • Marsh K, Zeuschner C, Saunders A et al (2009) Meeting nutritional needs on a vegetarian diet.st Fam Physician 38(8): 600-2.
    • Martin CL, Sotres-Alvarez D, Siega-Riz AM (2015) Maternal dietary patterns during the second trimester are associated with preterm birth. J Nutr 145(8): 1857-64.
    • Martin CL, Siega-Riz AM, Sotres-Alvarez D et al (2016) Maternal dietary patterns are associated with lower levels of cardiometabolic markers during pregnancy. Paediatr Perinat Epidemiol 30(3): 246-55.
    • Martínez-Galiano J, Olmedo-Requena R, Barrios-Rodríguez R et al (2018) Effect of adherence to a Mediterranean diet and olive oil intake during pregnancy on risk of small for gestational age infants. Nutrients 10(9).
    • Martinez-Galiano JM, Amezcua-Prieto C, Salcedo-Bellido I et al (2018) Maternal dietary consumption of legumes, vegetables and fruit during pregnancy, does it protect against small for gestational age? BMC Pregnancy Childbirth 18(1): 486.
    • McAlpine JM, Vanderlelie JJ, Vincze LJ et al (2020) Use of micronutrient supplements in pregnant women of south-east Queensland. Aust N Z J Obstet Gynaecol.
    • McCauley ME, van den Broek N, Dou L et al (2015) Vitamin A supplementation during pregnancy for maternal and newborn outcomes. Cochrane Database Syst Rev(10): CD008666.
    • McGowan CA & McAuliffe FM (2013) Maternal dietary patterns and associated nutrient intakes during each trimester of pregnancy. Public Health Nutr 16(1): 97-107.
    • Meertens LJE, Scheepers HCJ, Willemse J et al (2018) Should women be advised to use calcium supplements during pregnancy? A decision analysis. Matern Child Nutr 14(1).
    • Meher S & Duley L (2006) Garlic for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev(3): CD006065.
    • Metayer C, Milne E, Dockerty JD et al (2014) Maternal supplementation with folic acid and other vitamins and risk of leukemia in offspring: a Childhood Leukemia International Consortium study. Epidemiology 25(6): 811-22.
    • Mi B, Wen X, Li S et al (2019) Vegetable dietary pattern associated with low risk of preeclampsia possibly through reducing proteinuria. Pregnancy Hypertens 16: 131-38.
    • Middleton P, Gomersall JC, Gould JF et al (2018) Omega-3 fatty acid addition during pregnancy. Cochrane Database of Systematic Reviews.
    • Mishra GD, Schoenaker DA, Mihrshahi S et al (2015) How do women's diets compare with the new Australian dietary guidelines? Public Health Nutr 18(2): 218-25.
    • Mitchell EKL, Martin JC, D'Amore A et al (2018) Maternal iodine dietary supplements and neonatal thyroid stimulating hormone in Gippsland, Australia. Asia Pac J Clin Nutr 27(4): 848-52.
    • Miyake Y, Tanaka K, Okubo H et al (2015) Intake of dairy products and calcium and prevalence of depressive symptoms during pregnancy in Japan: a cross-sectional study. BJOG 122(3): 336-43
    • Miyake Y, Tanaka K, Okubo H et al (2018) Dietary patterns and depressive symptoms during pregnancy in Japan: Baseline data from the Kyushu Okinawa Maternal and Child Health Study. Journal of Affective Disorders 225: 552-58.
    • Mizgier M, Jarzabek-Bielecka G, Mruczyk K (2019) Maternal diet and gestational diabetes mellitus development. J Maternal-Fetal Neonat Med: 1-10.
    • Mocevic E, Svendsen SW, Jorgensen KT et al (2014) Occupational lifting, fetal death and preterm birth: findings from the Danish National Birth Cohort using a job exposure matrix. PLoS One 9(3): e90550.
    • Mohanty AF, Siscovick DS, Williams MA et al (2016) Periconceptional seafood intake and pregnancy complications. Public Health Nutr 19(10): 1795-803.
    • Montoya Arizabaleta AV, Orozco Buitrago L, Aguilar de Plata AC et al (2010) Aerobic exercise during pregnancy improves health-related quality of life: a randomised trial. Journal of Physiotherapy 56(4): 253-58.
    • Mottola MF, Nagpal TS, Bgeginski R et al (2019) Is supine exercise associated with adverse maternal and fetal outcomes? A systematic review. British Journal of Sports Medicine 53(2): 82-89.
    • Munoz Balbontin Y, Stewart D, Shetty A et al (2019) Herbal medicinal product use during pregnancy and the postnatal period: a systematic review. Obstet Gynecol 133(5): 920-32.
    • Newman RB, Goldenberg RL, Moawad AH et al (2001) Occupational fatigue and preterm premature rupture of membranes. American Journal of Obstetrics and Gynecology 184(3): 438-46.
    • Ngongalah L, Rankin J, Rapley T et al (2018) Dietary and Physical Activity Behaviours in African Migrant Women Living in High Income Countries: A Systematic Review and Framework Synthesis. Nutrients 10(8).
    • NHMRC (2000) Nutrition in Aboriginal and Torres Strait Islander Peoples: An Information Paper. Canberra: National Health and Medical Research Council.
    • NHMRC (2013) Australian Dietary Guidelines. Canberra: National Health and Medical Research Council.
    • NHMRC & NZ Ministry of Health (2020) Nutrient Reference Values for Australia and New Zealand. Accessed: 7 Augugst 2020.) Physical activity during pregnancy and offspring neurodevelopment: A systematic review. Paediatr Perinat Epidemiol 32(4): 369-79.
    • Nino Cruz GI, Ramirez Varela A, da Silva ICM et al (2018) Physical activity during pregnancy and offspring neurodevelopment: A systematic review. Paediatr Perinat Epidemiol 32(4): 369-79.
    • Nossier SA, Naeim NE, El-Sayed NA et al (2015) The effect of zinc supplementation on pregnancy outcomes: a double-blind, randomised controlled trial, Egypt. Br J Nutr 114(2): 274-85.
    • NT DHCS (2007) NT Market Basket Survey, 2006. Darwin: NT Department of Health and Community Services.
    • O'Sullivan EJ, Rokicki S, Kennelly M et al (2020) Cost-effectiveness of a mobile health-supported lifestyle intervention for pregnant women with an elevated body mass index. Int J Obes (Lond) 44(5): 999-1010.
    • Oh C, Keats EC, Bhutta ZA (2020) Vitamin and mineral supplementation during pregnancy on maternal, birth, child health and development outcomes in low- and middle-income countries: a systematic review and meta-analysis. Nutrients 12(2).
    • Okubo H, Miyake Y, Tanaka K et al (2015) Maternal total caffeine intake, mainly from Japanese and Chinese tea, during pregnancy was associated with risk of preterm birth: the Osaka Maternal and Child Health Study. Nutr Res 35(4): 309-16.
    • Oostdam N, Bosmans J, Wouters MG et al (2012) Cost-effectiveness of an exercise program during pregnancy to prevent gestational diabetes: results of an economic evaluation alongside a randomised controlled trial. BMC Pregnancy Childbirth 12: 64.
    • Ota E, Mori R, Middleton P et al (2015) Zinc supplementation for improving pregnancy and infant outcome. Cochrane Database of Systematic Reviews.
    • Owe KM, Nystad W, Bø K (2009) Association Between Regular Exercise and Excessive Newborn Birth Weight. Obstetrics & Gynecology 114(4): 770-76.
    • Pang WW, Colega M, Cai S et al (2017) Higher maternal dietary protein intake is associated with a higher risk of gestational diabetes mellitus in a multiethnic asian cohort. J Nutr 147(4): 653-60.
    • Paskulin JTA, Drehmer M, Olinto MT et al (2017) Association between dietary patterns and mental disorders in pregnant women in Southern Brazil. Braz J Psychiatry 39(3): 208-15.
    • Pawlak R, Lester SE, Babatunde T (2014) The prevalence of cobalamin deficiency among vegetarians assessed by serum vitamin B12: a review of literature. Eur J Clin Nutr 68(5): 541-8.
    • Pena-Rosas JP, De-Regil LM, Gomez Malave H et al (2015) Intermittent oral iron supplementation during pregnancy. Cochrane Database Syst Rev(10): CD009997.
    • Peña-Rosas JP, De-Regil LM, Garcia-Casal MN et al (2015) Daily oral iron supplementation during pregnancy. Cochrane Database of Systematic Reviews.
    • Perales M, Calabria I, Lopez C et al (2016a) Regular Exercise Throughout Pregnancy is Associated with a Shorter First Stage of Labor. American Journal of Health Promotion 30(3): 149-57.
    • Perales M, Santos-Lozano A, Sanchis-Gomar F et al (2016b) Maternal Cardiac Adaptations to a Physical Exercise Program during Pregnancy. Med Sci Sports Exerc 48(5): 896-906.
    • Perales M, Valenzuela PL, Barakat R et al (2020) Gestational exercise and maternal and child health: effects until delivery and at post-natal follow-up. J Clin Med 9(2).
    • Pham NM, Do VV, Lee AH (2019) Polyphenol-rich foods and risk of gestational diabetes: a systematic review and meta-analysis. Eur J Clin Nutr 73(5): 647-56.
    • Piccoli GB, Clari R, Vigotti FN et al (2015) Vegan-vegetarian diets in pregnancy: danger or panacea? A systematic narrative review. BJOG: An International Journal of Obstetrics & Gynaecology 122(5): 623-33.
    • Pompeii LA, Savitz DA, Evenson KR et al (2005) Physical exertion at work and the risk of preterm delivery and small-for-gestational-age birth. Obstet Gynecol 106(6): 1279-88.
    • Prabha BS, Vijayaraghavan J, Maiya AG et al (2019) Effects of antenatal exercise programme and education on health related quality of life: a randomised controlled trial. J Clin Diag Res 13(2): YF01-YF04.
    • Raghavan R, Dreibelbis C, Kingshipp BL et al (2019) Dietary patterns before and during pregnancy and birth outcomes: a systematic review. Am J Clin Nutr 109(Supplement_7): 729S-56S.
    • Ramson JA, Middleton P, Bowman A (2020) Evidence Evaluation Report: Diet, Exercise and Weight Management in Pregnancy. Prepared by South Australian Health and Medical Research Institute and Ampersand Health Science Writing for the Australian Government Department of Health.
    • Rasmussen MA, Maslova E, Halldorsson TI et al (2014) Characterization of dietary patterns in the Danish national birth cohort in relation to preterm birth. PLoS One 9(4): e93644.
    • Rayman MP, Searle E, Kelly L et al (2014) Effect of selenium on markers of risk of pre-eclampsia in UK pregnant women: a randomised, controlled pilot trial. Br J Nutr 112(1): 99-111.
    • Renault KM, Carlsen EM, Norgaard K et al (2015a) Intake of carbohydrates during pregnancy in obese women is associated with fat mass in the newborn offspring. Am J Clin Nutr 102(6): 1475-81.
    • Renault KM, Carlsen EM, Nørgaard K et al (2015b) Intake of sweets, snacks and soft drinks predicts weight gain in obese pregnant women: detailed analysis of the results of a randomised controlled trial. Plos One 10(7).
    • Ritsmitchai S, Geater AF, Chongsuviwatvong V (1997) Prolonged standing and physical exertion at work during pregnancy increases the risk of preterm birth for Thai mothers. J Occup Health 39: 217-22.
    • Rodriguez-Blanque R, Sanchez-Garcia JC, Sanchez-Lopez AM et al (2018) The influence of physical activity in water on sleep quality in pregnant women: A randomised trial. Women Birth 31(1): e51-e58.
    • Rodriguez-Blanque R, Sanchez-Garcia JC, Sanchez-Lopez AM et al (2019a) Physical activity during pregnancy and its influence on delivery time: a randomized clinical trial. PeerJ 7: e6370.
    • Rodriguez-Blanque R, Sanchez-Garcia JC, Sanchez-Lopez AM et al (2019b) Randomized clinical trial of an aquatic physical exercise program during pregnancy. J Obstet Gynecol Neonatal Nurs 48(3): 321-31.
    • Rodriguez-Blanque R, Aguilar-Cordero MJ, Marin-Jimenez AE et al (2020) Water exercise and quality of life in pregnancy: a randomised clinical trial. Int J Environ Res Public Health 17(4).
    • Rumbold A, Ota E, Hori H et al (2015a) Vitamin E supplementation in pregnancy. Cochrane Database Syst Rev(9): CD004069.
    • Rumbold A, Ota E, Nagata C et al (2015b) Vitamin C supplementation in pregnancy. Cochrane Database Syst Rev(9): CD004072.
    • Saccone G & Berghella V (2016) Folic acid supplementation in pregnancy to prevent preterm birth: a systematic review and meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol 199: 76-81.
    • Salam RA, Zuberi NF, Bhutta ZA (2015) Pyridoxine (vitamin B6) supplementation during pregnancy or labour for maternal and neonatal outcomes. Cochrane Database Syst Rev(6): CD000179.
    • Salvesen KA & Morkved S (2004) Randomised controlled trial of pelvic floor muscle training during pregnancy. BMJ 329(7462): 378-80.
    • Salvesen KA, Stafne SN, Eggebo TM et al (2014) Does regular exercise in pregnancy influence duration of labor? A secondary analysis of a randomized controlled trial. Acta Obstet Gynecol Scand 93(1): 73-9.
    • Sanda B, Vistad I, Sagedal LR et al (2018) What is the effect of physical activity on duration and mode of delivery? Secondary analysis from the Norwegian Fit for Delivery trial. Acta Obstet Gynecol Scand 97(7): 861-71.
    • Saunders L, Guldner L, Costet N et al (2014) Effect of a Mediterranean diet during pregnancy on fetal growth and preterm delivery: results from a French Caribbean Mother-Child Cohort Study (TIMOUN). Paediatr Perinat Epidemiol 28(3): 235-44.
    • Schoenaker DA, Soedamah-Muthu SS, Mishra GD (2014) The association between dietary factors and gestational hypertension and pre-eclampsia: a systematic review and meta-analysis of observational studies. BMC Med 12: 157.
    • Schoenaker DA, Mishra GD, Callaway LK et al (2016) The role of energy, nutrients, foods, and dietary patterns in the development of gestational diabetes mellitus: A systematic review of observational studies. Diabetes Care 39(1): 16-23.
    • Seneviratne SN, Jiang Y, Derraik J et al (2016) Effects of antenatal exercise in overweight and obese pregnant women on maternal and perinatal outcomes: a randomised controlled trial. BJOG 123(4): 588-97.
    • Shand AW, Walls M, Chatterjee R et al (2016) Dietary vitamin, mineral and herbal supplement use: a cross-sectional survey of before and during pregnancy use in Sydney, Australia. Aust N Z J Obstet Gynaecol 56(2): 154-61.
    • Sharma SS, Greenwood DC, Simpson NAB et al (2018) Is dietary macronutrient composition during pregnancy associated with offspring birth weight? An observational study. Br J Nutr 119(3): 330-39.
    • Sherriff J, Hine T, Begley A et al (2019) Iodine-containing food practices of Western Australian pregnant women and ethnicity: An observational study. Nutr Diet.
    • Shin D, Lee KW, Song WO (2015) Dietary patterns during pregnancy are associated with risk of gestational diabetes mellitus. Nutrients 7(11): 9369-82.
    • Shiri R, Coggon D, Falah-Hassani K (2018) Exercise for the prevention of low back and pelvic girdle pain in pregnancy: A meta-analysis of randomized controlled trials. Eur J Pain 22(1): 19-27.
    • Simmonds LA, Sullivan TR, Skubisz M et al (2020) Omega-3 fatty acid supplementation in pregnancy-baseline omega-3 status and early preterm birth: exploratory analysis of a randomised controlled trial. BJOG 127(8): 975-81.
    • Singh GR, Davison B, Ma GY et al (2019) Iodine status of Indigenous and non-Indigenous young adults in the Top End, before and after mandatory fortification. Med J Aust 210(3): 121-25.
    • Sklempe Kokic I, Ivanisevic M, Uremovic M et al (2017) Effect of therapeutic exercises on pregnancy-related low back pain and pelvic girdle pain: Secondary analysis of a randomized controlled trial. J Rehabil Med 49(3): 251-57.
    • Skow RJ, Davenport MH, Mottola MF et al (2019) Effects of prenatal exercise on fetal heart rate, umbilical and uterine blood flow: a systematic review and meta-analysis. Br J Sports Med 53(2): 124-33.
    • Smith LK, Draper ES, Evans TA et al (2015) Associations between late and moderately preterm birth and smoking, alcohol, drug use and diet: a population-based case-cohort study. Arch Dis Child Fetal Neonatal Ed 100(6): F486-91.
    • Snijder CA, Brand T, Jaddoe V et al (2012) Physically demanding work, fetal growth and the risk of adverse birth outcomes. The Generation R Study. Occup Environ Med 69(8): 543-50.
    • Soto R, Guilloty N, Anzalota L et al (2015) Association between maternal diet factors and hemoglobin levels, glucose tolerance, blood pressure and gestational age in a Hispanic population. Arch Latinoam Nutr 65(2): 86-96.
    • Sridharan K & Sivaramakrishnan G (2018) Interventions for treating nausea and vomiting in pregnancy: a network meta-analysis and trial sequential analysis of randomized clinical trials. Expert Review of Clinical Pharmacology 11(11): 1143-50.
    • Starling P, Charlton K, McMahon AT et al (2015) Fish intake during pregnancy and foetal neurodevelopment--a systematic review of the evidence. Nutrients 7(3): 2001-14.
    • Stratakis N, Roumeliotaki T, Oken E et al (2016) Fish Intake in Pregnancy and Child Growth: A Pooled Analysis of 15 European and US Birth Cohorts. JAMA Pediatr 170(4): 381-90.
    • Stratakis N, Conti DV, Borras E et al (2020) Association of fish consumption and mercury exposure during pregnancy with metabolic health and inflammatory biomarkers in children. JAMA Netw Open 3(3): e201007.
    • Sun X, Li H, He X et al (2019) The association between calcium supplement and preeclampsia and gestational hypertension: a systematic review and meta-analysis of randomized trials. Hypertens Pregnancy 38(2): 129-39.
    • Switkowski KM, Jacques PF, Must A et al (2016) Maternal protein intake during pregnancy and linear growth in the offspring. Am J Clin Nutr 104(4): 1128-36.
    • Taniguchi C & Sato C (2016) Home-based walking during pregnancy affects mood and birth outcomes among sedentary women: A randomized controlled trial. Int J Nurs Pract 22(5): 420-26.
    • Tara F, Maamouri G, Rayman MP et al (2010) Selenium supplementation and the incidence of preeclampsia in pregnant Iranian women: a randomized, double-blind, placebo-controlled pilot trial. Taiwan J Obstet Gynecol 49(2): 181-7.
    • Tenorio MB, Ferreira RC, Moura FA et al (2018) Oral antioxidant therapy for prevention and treatment of preeclampsia: Meta-analysis of randomized controlled trials. Nutr Metab Cardiovasc Dis 28(9): 865-76.
    • Tielemans MJ, Steegers EAP, Voortman T et al (2017) Protein intake during pregnancy and offspring body composition at 6 years: the Generation R Study. Eur J Nutr 56(6): 2151-60.
    • Torjusen H, Brantsaeter AL, Haugen M et al (2014) Reduced risk of pre-eclampsia with organic vegetable consumption: results from the prospective Norwegian Mother and Child Cohort Study. BMJ Open 4(9): e006143.
    • Tuokkola J, Luukkainen P, Tapanainen H et al (2016) Maternal diet during pregnancy and lactation and cow's milk allergy in offspring. Eur J Clin Nutr 70(5): 554-9.
    • Vahdaninia M., Mackenzie H., Helps S. et al (2017) Prenatal intake of vitamins and allergic outcomes in the offspring: a systematic review and meta-analysis. J Allergy Clin Immunol Pract 5(3): 771-78.
    • van den Berg SW, Wijga AH, van Rossem L et al (2016) Maternal fish consumption during pregnancy and BMI in children from birth up to age 14 years: the PIAMA cohort study. Eur J Nutr 55(2): 799-808.
    • van den Broek M, Leermakers ETM, Jaddoe VWV et al (2015) Maternal dietary patterns during pregnancy and body composition of the child at age 6 y: the Generation R Study. The American Journal of Clinical Nutrition 102(4): 873-80.
    • Vejrup K, Brantsaeter AL, Knutsen HK et al (2014) Prenatal mercury exposure and infant birth weight in the Norwegian Mother and Child Cohort Study. Public Health Nutr 17(9): 2071-80.
    • Vejrup K, Schjolberg S, Knutsen HK et al (2016) Prenatal methylmercury exposure and language delay at three years of age in the Norwegian Mother and Child Cohort Study. Environ Int 92-93: 63-9.
    • Vejrup K, Brandlistuen RE, Brantsaeter AL et al (2018) Prenatal mercury exposure, maternal seafood consumption and associations with child language at five years. Environ Int 110: 71-79.
    • von Ehrenstein OS, Aralis H, Flores ME et al (2015) Fast food consumption in pregnancy and subsequent asthma symptoms in young children. Pediatr Allergy Immunol 26(6): 571-7.
    • Wall CR, Gammon CS, Bandara DK et al (2016) Dietary Patterns in Pregnancy in New Zealand-Influence of Maternal Socio-Demographic, Health and Lifestyle Factors. Nutrients 8(5).
    • Wang M, Wang ZP, Gao LJ et al (2015a) Maternal consumption of non-staple food in the first trimester and risk of neural tube defects in offspring. Nutrients 7(5): 3067-77.
    • Wang M, Li K, Zhao D et al (2017) The association between maternal use of folic acid supplements during pregnancy and risk of autism spectrum disorders in children: a meta-analysis. Mol Autism 8: 51.
    • Wang T, Zhang H-P, Zhang X et al (2015b) Is folate status a risk factor for asthma or other allergic diseases? Allergy, Asthma & Immunology Research 7(6).
    • Wen SW, White RR, Rybak N et al (2018) Effect of high dose folic acid supplementation in pregnancy on pre-eclampsia (FACT): double blind, phase III, randomised controlled, international, multicentre trial. Bmj.
    • WHO (2010) Equity, Social Determinant and Public Health Programmes. Geneva: World Health Organization.
    • Wolf HT, Hegaard HK, Huusom LD et al (2017) Multivitamin use and adverse birth outcomes in high-income countries: a systematic review and meta-analysis. Am J Obstet Gynecol 217(4): 404 e1-04 e30.
    • Woodley SJ, Boyle R, Cody JD et al (2017) Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews.
    • Xu A, Cao X, Lu Y et al (2016) A meta-analysis of the relationship between maternal folic acid supplementation and the risk of congenital heart defects. Int Heart J 57(6): 725-28.
    • Yang SY, Lan SJ, Yen YY et al (2020) Effects of exercise on sleep quality in pregnant women: A systematic review and meta-analysis of randomized controlled trials. Asian Nurs Res (Korean Soc Nurs Sci) 14(1): 1-10.
    • Zahiri Sorouri Z, Sadeghi H, Pourmarzi D (2016) The effect of zinc supplementation on pregnancy outcome: a randomized controlled trial. J Matern Fetal Neonatal Med 29(13): 2194-8.
    • Zareei S, Homayounfar R, Naghizadeh MM et al (2018) Dietary pattern in pregnancy and risk of gestational diabetes mellitus (GDM). Diabetes Metab Syndr 12(3): 399-404.
    • Zhang GQ, Liu B, Li J et al (2017) Fish intake during pregnancy or infancy and allergic outcomes in children: A systematic review and meta-analysis. Pediatr Allergy Immunol 28(2): 152-61.
    • Zhang Y, Lin J, Fu W et al (2019) Mediterranean diet during pregnancy and childhood for asthma in children: A systematic review and meta-analysis of observational studies. Pediatr Pulmonol 54(7): 949-61.
    • Zhu Y, Olsen SF, Mendola P et al (2017) Maternal consumption of artificially sweetened beverages during pregnancy, and offspring growth through 7 years of age: a prospective cohort study. Int J Epidemiol 46(5): 1499-508.
    • 12 Other than the recommendation on caffeine and the practice points, this section is a summary of information provided in the Australian Dietary Guidelines (NHMRC 2013).
    • 13 This section, including the consensus-based recommendation, is based on NHMRC (2010) NHMRC Public Statement: Iodine Supplementation for Pregnant and Breastfeeding Women. Canberra: National Health and Medical Research Council.
    Last updated: 
    5 February 2021

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