There are so many things to think about when it comes to pregnancy.
As a mom of 3 and doctor who specializes in preconception health, natural fertility, and supporting pregnant and postpartum women, I understand this intimately.
Yet, choosing the best prenatal vitamin for your body (one of the most important factors for a healthy pregnancy and baby!), is often given very little consideration.
That’s not to say doctors and midwives aren’t recommending them, because they are. Nor that women aren’t willing to take their prenatals, because they do.
The problem is, most healthcare providers have been trained to recommend “just any” prenatal supplement for all their maternity patients. If you’re lucky, your provider may suggest a supplement with DHA. But other than that, it’s a pretty generic prescription.
This is better than nothing of course, but I do not agree with this one-size-fits all approach.
The truth is, there is no perfect prenatal for everyone because we all have different nutrient needs, genetic backgrounds, and health concerns/histories. Plus, not all prenatals are created equal in terms of quality, nutrients, and delivery systems.
In my practice, we take an individual approach to prenatal vitamin recommendations for preconception, pregnancy, and postpartum/lactation (and yes, a prenatal is important during all of these stages). This article will explain why and offer tips on how you can navigate choosing the best prenatal for your individual needs.
Nutrients matter: not all prenatals are created equal
A prenatal vitamin is supposed to provide mother and baby with all the critical nutrients required for a healthy pregnancy, fetal development, postpartum recovery, and lactation season (if applicable).
Yet, many prenatals on the market (even the organic whole-foods-based ones!) are hopelessly outdated in terms of new research on which nutrients are essential, in which form, and in which quantities.
Here are the top nutrients to look for, which may be missing, in your prenatal vitamin.
Choline—and enough of it
Up to 95% of pregnant women aren’t getting enough choline. 1 This is partly due to diet (especially with vegans or those who avoid eggs, which are our greatest dietary source) and absorption issues, but it’s largely because their prenatals don’t contain enough of it…if any.
This is a big problem because choline is essential for things like
- cell membrane integrity (and you’re making a lot of cells during pregnancy),2
- methylation and preventing neural tube defects,3
- normal homocysteine levels—which plays a part in things like preeclampsia and low birth weight4,
- liver and gallbladder health5 (pregnancy can cause gallbladder disease),
- cognitive development and function,6
- placental health,7 and
- And mental/emotional well-being.8
How much choline should your prenatal have?
The bare minimum intake of choline during pregnancy is 450mg a day, and 550mg a day during lactation.9
However, this may not be optimal for every woman. Especially those with genetic mutations (SNPs) of the PEMT gene and MTHFR (nutrigenomic testing will reveal this), which can increase your dietary choline needs.10
So 450mg minimum, and possibly more depending on your genetics.
Folate…not folic acid
So here’s the deal, I highly recommend methylfolate over folic acid during pregnancy for two reasons.
#1: The research says that methylfolate is better absorbed than synthetic folic acid.11 #2: Genetic variations, such as MTHFR (which affect approximately 50% of the population12) and digestive health issues greatly hinder proper metabolism of folic acid. The greater bioavailability of methylfolate makes it a no-brainer for pregnant women.
Thus, I always recommend looking for a prenatal vitamin with methylfolate because it’s easier to absorb in general and especially if you have a genetic variation.
Now, due to the detriments of folate deficiency during pregnancy, which include neural tube defects, I’ve gotten some pushback from other doctors who disagree with my stance on this. Their argument is that folic acid is just as good as methylfolate.
However, given the research and my personal clinical experience throughout the years, I stand by this recommendation whole-heartedly.
There is no harm in taking methylfolate and there is a potential risk in not taking it. So why not take it?
B-vitamins are extremely important for developing babies and pregnant women because they play a role in red blood cell health, DNA formation, brain health, and nervous system maintenance.13 They’re also helpful for quelling stress…which you don’t want during pregnancy or postpartum.
For the same reasons I recommend methylfolate vs. folic acid, I also recommend a prenatal with other activated/methylated B-vitamins, including:
- Vitamin B12 in the form of methylcobalamin, hydroxocobalamin and/or adenosylcobalamin (not cyanocobalamin)
- Vitamin B6 as pyridoxal-5-phosphate
- Vitamin B2 as riboflavin-5-phosphate
B-vitamin deficiency is pretty rampant across male and female populations. This is partly because of poor diet and stress, which deplete stores. But also due to SNPs/genetic variations and gut health issues.
The amounts of B-vitamins you need, especially B12, can vary quite a bit. However, make sure your prenatal has at least 100% of the daily value of all these. Then, get yourself tested so you know where you’re at in terms of nutrients levels (more on this to come).
Vitamin A as a mix of carotenoids and retinyl palmitate
There’s been some confusion in the pregnancy world about supplementing with vitamin A that I’d like to clear up.
It is true that high dose vitamin A should be avoided during pregnancy because it can increase the rate of birth defects.
…that doesn’t mean you should avoid all vitamin A! In fact, many of us don’t get enough because most of our vitamin A comes from carotenoids (found in carrots, sweet potatoes, etc.) which is a vitamin A precursor.
For some of us, carotenoids don’t always convert that well to preformed vitamin A, which is found in animal products. The genetic mutation, BCMO1 can decrease your capacity to convert beta-carotene into active vitamin A (those pesky genes again!).
Diet and lifestyle also play a role. For example, vegetarians and vegans may require supplementation.
In traditional cultures, women got plenty of preformed vitamin A from eating organ meats, egg yolks, pastured dairy, etc. and had healthy babies. Vitamin A is also essential for supporting
- immune health,14
- egg health,15
- early embryo formation,16
- fetal growth,17
- fetal bone metabolism,
- vision,18 and
- lung development in-utero.19
So there’s a place for vitamin A in our diets and prenatal vitamins. A possible exception would be if you eat consistently large amounts of foods rich in preformed vitamin A like organ meats, pastured dairy, egg yolks, etc. In that case, you’d want to get your levels checked before adding additional supplementation. But I’ve never seen this issue clinically.
For optimal absorption and safety, I look for a mixture of preformed vitamin A as retinyl palmitate with mixed carotenoids in a good prenatal.
Note that I do NOT recommend supplementing with additional vitamin A during preconception/pregnancy/lactation. During these stages women should not exceed 3,000 mcg of preformed vitamin A (retinyl palmitate) per day.
Chelated minerals bound to glycine
Adequate intake of minerals, such as iron and magnesium, is also important to prenatal health.
When it comes to minerals, the most important things to be aware of are your individual iron needs and the forms of various minerals within your prenatal multi.
The World Health Organization estimates that about 41% of pregnant women are iron deficient.20 This is a big deal, because iron is essential for the formation of healthy blood, the transportation of oxygen, formation of DNA, and to prevent anemia. And since your blood volume doubles during pregnancy and you’re sharing a bunch of DNA with your baby, having optimal reserves is critical.
Thus, supplementation with iron is generally recommended during pregnancy to meet the iron needs of mother and baby. Research has shown that when detected early in pregnancy, iron deficiency anemia is associated with a > 2-fold increase in the risk of preterm delivery. Maternal anemia when diagnosed before mid pregnancy is also associated with an increased risk of preterm birth.21
Unfortunately, regular iron screenings aren’t generally part of standard prenatal care unless anemia is detected in the initial blood work.
Yet, research shows that close monitoring of iron status during pregnancy (and ideally during preconception) to achieve optimal iron levels is critical to mother and baby.
In addition to an increased risk of preterm birth, iron deficiency can also cause negative impacts on the fetal brain and complications during delivery and postpartum.22
All that said, not ALL women require extra iron supplementation. Some pregnant women are already iron-sufficient, and in some cases may be iron-overloaded.
Supplementing iron in an iron-sufficient or iron-overloaded person, can lead to an increased risk of fetal growth restriction, preterm delivery, preeclampsia, gestational diabetes, inflammation, and oxidative stress.23
Plus, by failing to measure iron, we may miss the diagnosis of hemochromatosis, which is an inborn error of iron metabolism that causes excess iron accumulation. These women should not be supplementing with extra iron in a standard prenatal vitamin.24
All this brings us back to the importance of regular testing of your iron (CBC/complete blood count) and stored iron (known as ferritin) levels, to determine the best prenatal for you. It’s not expensive, complicated or risky and the benefits are immense for mother and baby.
When it comes to the forms of minerals such as iron, magnesium, and zinc look for minerals bound to glycine. This form of delivery system is superior in terms of absorption while being gentle on your stomach.25
These are usually listed with the words “glycinate”, “chelate”, or “bisglycinate” next to them (as in “magnesium glycinate” or “calcium bisglycinate”). Albion’s minerals are my favorite in terms of absorption, and you’ll see their name on various supplement labels.
Your prenatal should contain iodine
All prenatals should contain iodine. This essential trace mineral is important to proper brain development in the fetus, protects against miscarriage, birth defects, and stillbirth, and helps keep mom’s production of thyroid hormone stable while protecting immunity. Women are often deficient due to a lack of iodine in most Western diets.26
Plus, in some regions of the world, iodine-deficient soils are common, increasing the risk of iodine deficiency among people who consume foods primarily from those areas.
Salt iodization programs, which many countries have implemented, have dramatically reduced the prevalence of iodine deficiency worldwide
In the United States, iodine status in pregnant women is considered mildly deficient. Therefore, the Endocrine Society, the American Thyroid Association, the Teratology Society, and the American Academy of Pediatrics recommend that women receive prenatal vitamins containing 150 μg of iodine daily during preconception, pregnancy, and lactation.27
If you’re concerned about taking supplemental iodine due to a thyroid issue, talk to your doctor before avoiding it.
In my practice, I almost never recommend against taking iodine during preconception, pregnancy, and lactation because it’s so darn important. Generally speaking, you and your baby need this essential mineral, so don’t avoid it unless your doctor recommends you do so.
What about EPA and DHA?
Ideally your prenatal would contain the omega 3 fatty acids EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) which support normal fetal development including cognitive, neuronal, retinal, and immune function.28
Optimal maternal serum levels of DHA have also been associated with a woman’s level of insulin sensitivity during pregnancy. Which suggests that optimal intake of omega-3s are important in the preconception phase too.
Unfortunately, most women do not get enough omega-3s from their diets due to a lack of seafood consumption and/or consumption of low-omega-3 foods in general.29
However, they can (and should) be taken separately if your prenatal does not contain them. And even if it does, it’s probably not enough. Which is why I almost always recommend taking these as an additional supplement.
Note: before we move onto the other aspects of choosing a quality prenatal, I want to emphasize that this isn’t a list of all the nutrients that should be in a prenatal such as vitamin C, vitamin E, calcium, etc. but it gives you a good idea of what to look for in a top quality prenatal.
It’s also worth noting that typically vitamin D3 should be taken separately in larger amounts based on bloodwork. You may also benefit from taking other nutrients separately to ensure optimal dosing such as: EPA and DHA, calcium, magnesium, iron, and vitamin C.
How do you know what you need? Test don’t guess!
We’ve alluded to this throughout the article, but the only way to know exactly what your body needs is through accurate testing (beyond just CBC).
We like to do nutrigenomic testing, which gives us information on which nutrients and foods your body likes and needs (like Vitamin A, B-vitamins, folate, and omega-3s) based on genetics. It also alerts us to any genetic mutations/SNPs which may affect nutrient metabolism.
In addition, I recommend a variety of tests to check for functional markers or vulnerabilities, including:
- Vitamin D
- Vitamin A
- Iron + Ferritin (stored iron)
- RBC Folate
- RBC Magnesium
And don’t forget labs for thyroid function! Which I wrote all about this in my article: Thyroid, Fertility, and Pregnancy: An Integrative Functional Approach
Ideally, you’d get this information before becoming pregnant so you can restore any deficiencies and stockpile your nutrient stores. However, that’s a perfect-world scenario that’s not always accessible or realistic to everyone…and that’s okay! The most important thing is to start where you’re able, and if that means you’re already pregnant then now’s the perfect time.
If your healthcare provider doesn’t offer these tests (and not all will), just ask. It’s your right as a patient to have whatever information about your body that will help improve your health. You can also order some of these labs yourself if your provider doesn’t offer them, including a nutrigenomics test here.
Quality matters: choose pharmaceutical-grade supplements
Taking high-quality supplements is important, period. But it’s especially important during pregnancy, when getting enough nutrients and protecting your baby from toxins is paramount.
This is why I only recommend pharmaceutical-grade supplements and prenatals. These supplements are typically available through integrative functional medicine doctors and practitioners, and are not found in drug stores or natural food stores.
What sets them apart is they are manufactured in FDA-registered, GMP-certified facilities under the same standards as pharmaceutical drugs. GMP facilities are subject to FDA audits to ensure standards are being met.
Generally, these supplements exceed standards set by the United States Pharmacopeia (USP) for supplement manufacturing. They are third-party tested for ingredient identity and things like heavy metals, mold, solvent residues, allergens, and bacteria. They are also free from fillers, binders, and synthetic ingredients like gluten, dyes, preservatives, soy, dairy, and chemical additives.
In other words, pharmaceutical-grade supplements ensure you and your baby are receiving exactly what is printed on the label, with none of the toxic or questionable stuff you need to avoid.
The top 5 prenatal vitamin brands I recommend
#1: Metagenics PlusOne Prenatal Packs
The thing I really like about this one is it contains a good balance of EPA and DHA, choline, and carnitine—which is unique and wonderful for mitochondrial support, inflammation, healthy glucose levels, fatigue during pregnancy, and for babies small for gestational age.30, 31, 32.
Carnitine supplementation is being studied in the prevention of gestational diabetes (something I struggled with myself). One study finds that “L-carnitine supplementation in pregnancy in sufficient doses avoids a striking increase of plasma FFAs, which are thought to be the main cause of insulin resistance and consequently gestational diabetes mellitus (GDM).”33
This particular prenatal also has a good amount of iron (30 mg), which is great for those who need it. The iodine amount is right on track (176 mcg), choline is optimal at 450 mg, it has folate in the right form and potency (calcium L-5-methyltetrahydrofolate 1665 mcg), and a balanced form and amount of vitamin A (mixed carotenoids and retinyl palmitate) 1650 mcg.
This is a simpler formula than Metagenics, so most women need to supplement with extra fish oil. But I like it because it contains a good amount of choline, plus trimethylglycine (TMG) which helps hack the methylation cycle and decrease the requirement for choline. So, it has less choline but the TMG makes up for that.
It also has more moderate B vitamin and iron support, which is appropriate for some women with adequate or near-optimal levels. The mineral content is great with gentle forms of zinc (over 100% DV), magnesium, calcium, copper, and others. And all the right levels of iodine, L-methylfolate, and vitamin A.
It does not contain EPA/DHA/omega-3s, so for most women I recommend that they supplement with a separate fish oil.
#3: Seeking Health Prenatal Essentials
Prenatal Essentials is iron-free and contains extra iodine (220 mcg), the good form/amount of vitamin A/beta carotene and folate, 1000 IUs of vitamin D plus K2, 100 mcg of B12, and plenty of other B vitamins. It does not contain choline or EPA/DHA/omega-3s… so for most women I recommend that they supplement with these separately (Seeking Health has great options here, including Optimal PC which is their choline supplement).
This prenatal can be a life-saver if you’re taking other supplements because it’s just 2 capsules per day vs. 4-8 caps.
#4: Seeking Health Optimal Prenatal (capsules or powder)
The Optimal Prenatal is also iron-free, offers aggressive B vitamin support, extra iodine (250 mcg), 250 mg of choline, an excellent form and amount of folate, and the right mix/dosage of vitamin A. It also has some added herbs for liver support which can be helpful for morning sickness/pregnancy in general, and CoQ10 which is great for energy and cardiovascular support.
The potential downside is it’s 8 pills per day, which may be a lot if you’re taking other supplements. In which case, you may wish to consider the Prenatal Essentials listed above. Most women do need an additional fish oil. Also, if you’re iron deficiency that would require a separate iron supplement.
#5: Needed Prenatal Multi (capsules or powder)
This is another iron-free formula that offers excellent B vitamin support (especially B12), extra iodine (290 mcg), and a generous amount of choline (400 mg). It also has 4000 IU of Vitamin D3 with K2, which is unique in a prenatal and may even omit the need for additional Vitamin D supplementation. It’s rich in minerals, including zinc, selenium, and magnesium and contains a nice antioxidant blend of berries and superfoods which can benefit those with inflammatory issues.
The dose is 8 capsules which may be divided between meals. This multi may not be doable if you’re already taking a bunch of other supplements. But given the amount of nutrients in it, you may not have to take many additional supplements. Most women do need an additional fish oil. Again, since this one is iron-free, you may require a separate iron supplement depending on your levels.
How to choose the right prenatal for you? Test don’t guess!
Sorry to sound like a broken record, but the only way to know which prenatal is best for you and your baby is to get those nutrient tests mentioned above.
I also want to stress that although a prenatal vitamin is a wonderful and necessary way to ensure optimal nutrition during preconception, pregnancy, and lactation, it doesn’t replace a healthy diet.
What exactly does a healthy pregnancy diet entail? We (by BFF Dr. Alex Carrassco and I) cover this at length on Hey Mami in: The Hey Mami Approach to Healthy Eating. You can also check out my articles on preconception, fertility, pregnancy, and postpartum for more helpful tips.
Need some help supporting your body during preconception, pregnancy, or postpartum?
My team and I love to work with women throughout their journey to conception, pregnancy, and motherhood. Some of our specialties include supporting natural fertility, reproductive, and preconception health, hormonal imbalance, thyroid disease/Hashimoto’s, postpartum depletion, digestive issues, and optimizing your health during pregnancy.
If you’re located in Texas, Michigan, or Colorado click here to learn more about our approach to integrative functional medicine.
And if you already know which prenatal you need, click here to access these pharmaceutical-grade supplements via FullScript.