Preparing for a Healthy Pregnancy
By: Dr. Martha Tesfalul
In the US, nearly half of pregnancies are unplanned. Even though unplanned pregnancies can be safe, planning can help improve the chance of having a healthy pregnancy. Here are some frequently asked questions and tips to help get you or your loved ones prepared for the journey!
Why is planning in advance for pregnancy important?
Pregnancy is an important time both for the baby and for the mother. Babies' organs like the heart and spinal cord start to form in the first few weeks, before many women even know they are pregnant. Being pregnant demands a lot from the mother. Being healthy before and during pregnancy can help the baby grow well and the mother cope well with all the changes.
Who should plan for pregnancy?
Women with chronic medical conditions that increase pregnancy risk (e.g., diabetes, high blood pressure, certain autoimmune conditions) can decrease their risk by having these conditions well controlled before pregnancy. If you have a medical condition and are unsure if it may have an impact on pregnancy, you should talk with your primary care provider to learn more. Even women with no known medical problems can benefit from improving their nutrition, activity and overall wellness before getting pregnant.
The health of others beyond the mother is also important. Certain medical problems can impact men's sperm and thus their ability to get pregnant as well as their ability to be a supportive parent. There also medical conditions that can run in families, and knowing about that risk in advance can help guide a couple's plans for their own family. The health of others in the home and/or community can have an impact on pregnancy- for example, if someone near a mother is a cigarette smoker, that mother has higher risk of problems in pregnancy.
Preparing for pregnancy can be a great motivation for not only the future parents but also those who are around them to be in their best health.
What health care is important to have before becoming pregnant?
Before getting pregnant, it is important to be up to date on your routine health care and to have good control of any medical problems you may have. If you do not have a primary care provider because of insurance, you can explore resources like HealthCare.gov to get enrolled in health insurance as well as local free or sliding scale clinics to help you access care. Having the same provider over time has benefits, but being seen by different providers can still provide you with the chance to learn more about your health and how to better it.
Your primary care provider should be monitoring your blood pressure and weight to check if they are in healthy ranges for you. If not, then your provider can counsel and support you to get closer to a healthy ranges. Hypertension, or abnormally high blood pressure, is associated with many risks both inside and outside of pregnancy, but fortunately lifestyle changes and medications can help lower many of those risks. Being either underweight or overweight can increase the chance of having trouble getting pregnant and certain pregnancy complications- while it is not necessary to wait to be at one's target weight to become pregnant, getting closer to it while preparing or trying can be helpful.
In addition to blood pressure and weight assessments, routine screening should be done for conditions like mood disorders (e.g., anxiety, depression), cancer (e.g., Pap smears/HPV testing, mammograms) and infections (e.g., syphilis, HIV). You can learn more about recommendations around routine women's healthcare on the Women's Preventative Services Initiative Well-Woman Chart. If you have certain risk factors, different screening may be appropriate for you (e.g., earlier breast cancer or diabetes screening based on your family history).
Beyond the clear benefits to one's own health, having good control of certain medical conditions can decrease certain pregnancy risks. For example, women with diabetes that is not controlled can have very high blood sugars during the critical times of early fetal development, which increases the risks of major heart and neural/spinal tube problems that have major consequences for the baby. It is often more challenging emotional and clinically for those diagnosed with these more complicated conditions during pregnancy than beforehand.
It is also very important to tell your primary care provider that you are thinking about and/or planning on becoming pregnant, so that they can review anything you should know and/or do as it relates to your specific health and health care (e.g., potential medication changes). If you have any high risk factors, they may consider referring you to a Maternal-Fetal Medicine or other specialist for a consultation before you become pregnant- you should feel empowered to ask about such a referral if it does not come up.
Why is addressing mental health important?
Mental health is part of overall health. The brain is a critical organ, and when it is troubled by disorders such as depression, there can be huge consequences for the health of other things including pregnancy. Both trying to become pregnant and actually being pregnant can come with a lot of stress, which can lead to and/or worsen existing mood disorders such as anxiety and depression for couples. Also, similar to medical conditions like diabetes, mental health conditions like bipolar disorder can be associated with increased pregnancy risk, particularly in the postpartum period.
Many people benefit from seeing providers who specialize in mental health (e.g., psychiatrists, therapists) as well as medications to help. And we all can benefit from doing things that support mental wellness including being physically active, getting restful sleep, and having supportive family and friend networks.
With regard to relationships, an important issue that can greatly impact mental and physical health is intimate partner violence, which can worsen during pregnancy and postpartum- if you have any concerns for your safety, you should talk with your primary care provider and/or someone near you.
How should preparing for pregnancy impact my existing medication and supplement use?
One key thing is that you should talk with your health care provider before adjusting and/or stopping any prescribed medications- while it may be appropriate, there is also a chance that it may not be and could put one's health and pregnancy at risk.
First, it important to let your provider know all the medications and supplements, even those you get over-the-counter without a prescription. Supplements do not have to go through the same process of proving safety or efficacy as medications, but they can have significant impacts on one's health.
Second, it is important to know about the safety of the medications and supplements you are on during pregnancy. In addition to your provider, one very helpful resource is MotherToBaby, which is free and not only has a number of fact sheets on many medications and supplements but also allows for people to submit questions that they will try to answer (e.g., for information about a medication that is not reviewed).
Finally, if there are medications and/or supplements that are not ideal for continuing during pregnancy, you should work with your provider(s) to determine the best strategy for planning for pregnancy. In some cases, it is appropriate to stop or to switch to an alternative medication that is safe in pregnancy even before becoming pregnant. In other cases, it is not ideal to be off a particular medication any longer than necessary and thus staying on it until pregnancy is achieved and then coming off is appropriate. In some cases, it can be helpful to talk with a Maternal-Fetal Medicine or other specialist familiar with your condition(s) and medication(s) in pregnancy to ensure that you are not being taken off of any medication unnecessarily.
Are there recommended supplements to start when preparing for pregnancy?
Pregnancy requires that the mother provides many nutrients to the baby. Though ideal to get them from a well-balanced diet, for many individuals, taking supplements is needed to get enough for pregnancy. Taking a prenatal vitamin at least a month before trying to get pregnant can help get the most important ones on board. Here are a few of the key vitamins, minerals and other nutrients to keep in mind when trying to get pregnant:
•Folate/folic acid (vitamin B9)- This vitamin is critical to the development of the neural tube, which goes onto the brain and spine. All women of reproductive age are recommended to have 400mcg of folic acid daily. You may need to be on even higher doses with certain medications (e.g., seizure medications) or if you have a prior child with a neural tube defect. Since it is hard to get 400mcg with just diet alone (more information about potential dietary sources here), it is best to start supplementing at least a month before becoming pregnant to lower your risk of complications.
•Iron- This mineral is important for your red blood cells and their ability to carry oxygen around your body and to a growing pregnancy. Anemia, that is low red blood cell counts, increases the risk of certain health and pregnancy complications. It is recommended that women take 18mg of elemental iron daily and increase it to 27mg during pregnancy, with higher doses being recommended if you have anemia. Iron can be found in many foods, such as red meat and dark leafy greens, but unfortunately iron deficiency is the most common nutritional deficiency so taking a supplement is often appropriate. Not all prenatal vitamins have full recommended dose of iron, especially if they are gummy. Iron is best absorbed with vitamin C or something acidic (and not with dairy products), so having your dark leafy salad with a citrus dressing or your supplements with a small amount of grapefruit or orange juice can help you get the biggest benefit.
•Vitamin B12- This vitamin is important many functions, including your red blood cells. The main source of it is from animal-based foods (e.g., dairy, eggs, fish, meat, poultry), so vegans are a risk for having low levels unless they eat fortified foods and/or take supplements.
•Vitamin D- Vitamin D is important particularly bone health. It can be found in certain foods (e.g., egg yolks, fatty fish) and produced with sunlight exposure. Unfortunately, it is fairly common in our community to have low levels of vitamin D, which can be associated with pregnancy complications. If your provider determines that you have low vitamin D levels, it will important to take the supplementation that they recommend. If you do not have a deficiency, it is not clear if there is benefit to taking extra vitamin D if you have adequate levels, especially since it is possible to have side effects from too much of it. Getting from your diet avoids the risks of sun exposure, but you can get the benefits of sunshine more safely by using sunscreen.
•Calcium- Like vitamin D, calcium is important for bone health and low levels can increase the risk of pregnancy complications. Because the developing pregnancy needs calcium for the development of bones, especially in the last of trimester, stores of it are important to have to avoid having to take too much calcium from the mother's own bones. How much is recommended depends on age, but is 1000 mg daily for women ages 19 - 50. Dairy products are good sources of it, but there are also other foods with it for those who are lactose intolerant or are vegan.
•Choline- This nutrient plays an important role in brain development and can be found in foods like chicken, beef, eggs, soy, and peanuts. Many prenatal vitamins do not have this so it is important to make sure that you are getting it in your diet or have a supplement with it.
•Omega-3 fatty acids- Found in foods like fish, eating a diet rich in these nutrients are thought to have a lot of different health benefits including for the heart and in pregnancy. Unfortunately, large studies have shown mixed benefit of taking omega-3 fatty acid supplements, so it is not yet clear if it worth recommending beyond what comes from a health diet with such foods.
Not all vitamins or supplements are good, even if advertised as "natural" or "organic." Vitamins A, D, E and K can stick around in the fat and get to dangerous levels if taken in excess of what your body needs. Vitamin A in particular can cause birth defects in high levels, though too low of levels can also be associated with problems. Also taking too much of one nutrient can cause downstream consequences (e.g., too much zinc can cause copper deficiency), so it is best to have a balanced diet that provides these nutrients in combinations found in nature.
Are there foods, drinks or other substances that such be avoided if trying to get pregnant?
Most foods that are healthy to eat for the general public are safe to eat while planning to become pregnant. That said, there are foods that have higher risk of having infections that can make anyone sick but are more likely to have serious risk in pregnancy- these include raw, un- or undercooked or cold meat and fish (e.g., kitfo, raw sushi)- you can learn more about these here. While you can continue to eat these while trying to become pregnant, it is good to be aware that avoiding these during pregnancy can lower related risks.
Speaking of fish, while some people might think that it should be avoided before or during pregnancy because of concern for mercury, there is evidence to support that eating it can provide important health benefits, including being a good source of omega-3 fatty acids. It however is important to pick ones with lower mercury content and be mindful of serving sizes- this website from the Food and Drug Administration has a lot of great information on this topic.
Many of us love our coffee and tea, but in pregnancy it is recommended to limit caffeine to have less than 200mg per day, which would be approximately a 12 oz cup of coffee. While you can wait until pregnancy to cut back, some people can get withdrawal symptoms (e.g., headaches, irritability) if they typically drink a lot, so it might be helpful to start cutting back in preparation for pregnancy.
Alcohol use in pregnancy is the leading cause of preventable birth defects and developmental delay. Outside of pregnancy it can increase the risk of many health conditions, especially if had in high amounts. For women, guidelines recommend women have 1 or fewer drinks a day if not pregnant and not to drink if pregnant as it is unclear if there is any level that does not increase risk of complications. Heavy drinking can also impact ovulation and sperm quality and increase the risk of miscarriage. Not drinking alcohol while trying to get pregnant is the safest for your overall health and pregnancy.
Stopping tobacco use is recommended for anyone, especially those who are trying to become pregnant because it can impact fertility as well as increase the risk of ectopic pregnancy, that is a potentially life-threatening pregnancy that implants outside of the uterus. It is also associated with many pregnancy risks, and newer data suggests that vaping is as well. Stopping illicit drugs such as cocaine, heroin, and meth is also recommended for personal health and pregnancy benefits.
If you need support around alcohol or drug use, please talk to your provider and check out resources such as the Substance Abuse and Mental Health Services Administration's National Helpline (1-800-662-HELP, open 24/7 through the year) to learn about strategies and get the support you need.
What vaccinations are recommended before pregnancy?
Routinely recommended vaccinations as well as any recommended based on your personal risk factors should be received as advised by your primary care provider. Immunity against chickenpox, measles and rubella before pregnancy is ideal because they can cause serious pregnancy complications, but the vaccines for them cannot be given during pregnancy. If you do need to get these particular vaccines, it is recommended to wait one month before trying to get pregnant.
Vaccination to prevent COVID-19 is also recommended prior to pregnancy as the disease is associated with risk of serious illness and death both inside and outside of pregnancy. If you become pregnant before getting vaccinated, the recommendation is to get it during pregnancy because of growing evidence of its safety and benefits in that time. While there are rumors of COVID-19 vaccines causing infertility, there is no evidence confirming this to date, and many professional societies including the American Society for Reproductive Medicine recommend COVID-19 vaccination for those considering pregnancy.
What pregnancy-specific testing can be done before pregnancy?
Some people want to explore genetic testing options to know their risk of being a "carrier" of a gene that cause a genetic condition in their children such as sickle cell trait.
If you, your partner, and/or a close family member (e.g., mother, father, sibling, child) has a known or possible genetic condition, you should talk with your primary care provider about seeing a genetic counselor or someone who can talk with you more about potential testing options both inside and outside of pregnancy.
Even for those without any personal or family history of any genetic condition, there is still a chance of being a carrier for a genetic disorder. All pregnant people are to be offered carrier screening for the conditions of cystic fibrosis, spinal muscular atrophy and hemoglobinopathies (e.g., sickle cell) and ideally these can be done when contemplating pregnancy though coverage can vary. There are also many other conditions for which screening can be done though not yet routinely recommended in or outside of pregnancy for most patients.
What are things to keep in mind around birth control?
You can continue methods of birth control up until you are ready to start trying to become pregnant. There is no need for a cleanse or wash out period. However, some forms of birth control can affect one's periods for months after stopping them- specifically some women's bodies may take a longer time to return to normal ovulation (release of eggs from the ovaries) after receiving the injection of Medroxyprogesterone (Depo Provera) and the patches. In contrast, removal of intrauterine devices (e.g., Mirena, Paragard) or stopping methods like birth control pills results in faster return of fertility for many women.
What are some helpful tips for actually getting pregnant?
How to get pregnant can be a whole separate post, but ultimately the goal is for a healthy egg to meet a healthy sperm. Once released from the ovaries, eggs can only survive for 12-24 hours without being fertilized by sperm. Sperm can live for up to 5 days, so if a woman has had sex up to 5 days before or within 1 day of ovulating, what some call "the fertility window", there is a chance they can become pregnant. Those chances can be increased by having sex at least every other day around the time of ovulation- more sex than that is not harmful, and there are no particular positions that are clearly better than others.
One challenge is predicting when your body is going to ovulate, that is release an egg. Tracking periods on a period tracker can be helpful as many will help predict when you ovulate as well as when you can expect a period if you do not become pregnant. On average, most women will ovulate 2 weeks before their period, so if your cycles are predictable, it is possible to calculate your fertility window either on tracker apps or using online calculators. Another popular option for determining when you are going to ovulate is using ovulation prediction kits, which are available over-the-counter or online. They come with their own instructions for use.
It is helpful to have pregnancy tests available for when you are trying to conceive- many dollar stores will carry them as well as drug stores and online. If you are late for your period, then you can take one and if positive, it is important to document when your last period started because your health provider will use that to determine how far along the pregnancy is.
What are the chances of becoming pregnant and of infertility?
Approximately 20% of couples will become pregnant during their first month of trying with the strategy noted above. Another 50% will become pregnant after 6 months of trying. About 10-15% of couples will not be able to get pregnant after 12 months of trying (or 6 months if the woman is 35 years or older) and will thus be said to have infertility. In up to one third of cases the cause of infertility is not clear or due to both male and female factors, and in the remaining cases are due to male and female factors are very similar rates- this is often surprising to people who often think the female factors are more likely to be the issue.
As noted above, it is important to let your health care provider know if you are trying to become pregnant as well as if you are having challenges. For women who are younger than 35 years old, more evaluation for potential causes of infertility are recommended after 12 months of trying without becoming pregnant. For women who are 35 years or older, such evaluation is recommended after 6 months. The evaluation may include things like lab tests and imaging of the uterus. For some couples, evaluation even earlier than 6-12 months of trying is become pregnant is helpful, for example if the woman does not have regular periods or if the man has medical problems like chronic kidney disease.
Hopefully, the information above is helpful to you! Below are resources for you to learn more about some of the topics reviewed. If you have any additional questions or concerns about what was shared above, please email habeshahealth@gmail.com.
Resources
Preparing for Pregnancy:
General Health Recommendations :
Women's Preventative Services Initiative Well-Woman Chart
Medications, Supplements, Food, and Other Exposures:
National Institutes of Health's Dietary Supplement Fact Sheets
Fertility/Infertility:
Office on Women's Health Webpage on Infertility
American Society for Reproductive Medicine's Patient Fact Sheets & Info Booklets
And of course, the content of Habesha Health, which is focused on improving the health of our community including those who are considering becoming pregnant!
