Pre-Pregnancy Care and Prenatal Care

This plan includes your and your partner’s plans for the number and timing of pregnancies based on your values and life goals. Sharing your life plan with your health care provider can help address any potential problems before you conceive.²

You can reduce the chance that you will be diagnosed with gestational diabetes (high blood sugar diagnosed during pregnancy) by taking steps to improve your diet and lifestyle before you get pregnant. Gestational diabetes can increase the risk to your health as well as your infant's. In addition, pre-pregnancy exercise is also associated with lower risk for gestational diabetes, and the benefit increases with more vigorous levels of exercise.

Here are some specific dietary suggestions for women who are planning for a pregnancy:^3,4,5,6

• Increase your intake of fiber. Eating 10 more grams of fiber in the form of cereals, fruits, and vegetables is associated with 26% lower risk of gestational diabetes.¹⁸
• Reduce consumption of sugar-sweetened cola. Women who drank five or more such beverages per week before they got pregnant were at greater risk of gestational diabetes.
• Eat less red meat, processed meats, and animal fats and cholesterol. Eating less of these foods before pregnancy can decrease the chances of developing diabetes when you are pregnant.
• Replace animal protein with protein from nuts to lower your risk of gestational diabetes. Studies have shown that substituting vegetable protein for animal protein before pregnancy can decrease risk of gestational diabetes by about half.

Folic acid is a B vitamin (B9). It helps produce and maintain new cells.⁷ This is especially important during times when the cells are dividing and growing rapidly such as infancy and pregnancy.⁸

The United States Public Health Service recommends that all pregnant women and “women of childbearing age [15 to 44 years] in the United States who are capable of becoming pregnant should consume [a supplement containing] 0.4 mg of folic acid per day for the purpose of reducing their risk of having a pregnancy affected with spina bifida or other NTDs.” ⁹

Although a related form of folic acid (called folate) is present in orange juice and leafy, green vegetables (such as kale and spinach), folate is not absorbed as well as folic acid.¹⁰ Studies show that taking folic acid for 3 months before getting pregnant and for 3 months after conceiving can reduce the risk of NTDs such as spina bifida ^11,12 by up to 70%.¹³

Ask your health care provider if you need a booster for any vaccines. Some vaccines can be given during pregnancy, but the rubella (German measles) and varicella (chicken pox) vaccines are recommended before you get pregnant.

Many health problems affect not only the pregnant woman but also the developing infant. Some examples are diabetes, hypertension (high blood pressure), infections, asthma, seizure disorders, and maternal phenylketonuria (an inherited condition in which the pregnant woman’s body can’t break down the amino acid phenylalanine [pronounced fen-l-AL-uh-neen], resulting in high levels in her blood). Getting health problems under control before and during pregnancy reduces the risk of miscarriage and stillbirth as well as other health problems for the infant.¹¹

During pregnancy, these behaviors can increase the risk for sudden infant death syndrome (SIDS), preterm birth, fetal alcohol spectrum disorders, and NTDs.¹⁴ If you are trying to quit smoking, drinking, or doing drugs and you need help, talk to your health care provider about support groups or about medications.

Advice, tips, and support to help women quit smoking (including expecting mothers) are available through the Smokefree Women website.

Obesity may make it more difficult to become pregnant.¹⁵ Being overweight or obese also puts you at risk for complications during pregnancy, such as high blood pressure, preeclampsia, gestational diabetes, and stillbirth, and increases the chances of cesarean delivery.

NICHD researchers have found that obesity can increase your child’s risk of a congenital (pronounced kon-JEN-ih-tal) heart defect (a problem with the heart that is present at birth) by 15%.¹⁶ Research has also uncovered a link between obesity and NTDs.¹⁶

Talk to your health care provider about what a healthy weight is for you and about a plan to help you achieve it.

Your health care provider will ask for information about your family’s genetic and health history. You may be referred for genetic counseling if certain conditions run in your family or if a family member was born with a physical abnormality or an intellectual and developmental disability. ¹³

Good mental health means you feel good about your life and value yourself. It’s natural to worry or feel sad, anxious, or stressed at times. However, if these feelings do not go away and they interfere with your daily life, it’s important to seek help before you get pregnant.¹⁴ Hormonal changes and other situations during pregnancy can worsen depression.

Many people are familiar with the phrase “postpartum depression,” meaning depression that occurs after the birth of a baby. But we now know that it’s not just during the postpartum period, and it’s not just depression.

Women experience depression and anxiety, as well as other mental health conditions, during pregnancy and after the baby is born. These conditions can have significant effects on the health of the mother and her child. Getting mentally healthy before you get pregnant can help minimize the effects of these conditions.

Learn more about how Moms’ Mental Health Matters.

A blood test can determine whether you are vaccinated against rubella (also called German measles). Getting rubella while you are pregnant can harm the fetus. You should be vaccinated against rubella before you get pregnant.¹

STIs such as gonorrhea, syphilis, chlamydia, and HIV can make it hard for you to get pregnant and can also harm you and your infant. HIV can be passed from a woman to her infant during pregnancy or delivery. This risk is less than 2% if certain HIV medications are taken during pregnancy.² Learn more about infections that can affect your pregnancy.

Depending on your or your partner's health history, your health care provider may refer you to a genetic counselor to help you determine if you are at an increased risk for passing on a genetic disorder, such as cystic fibrosis, Fragile X syndrome, or sickle cell disease, You can request pre-pregnancy carrier screening, which involves a sample of blood or saliva.³ Find a genetic counselor  through the National Society of Genetic Counselors.

Your doctor may want to perform other tests depending on your risk for other problems such as anemia (a condition that causes a low red blood cell count¹) or hepatitis (a liver infection that can be passed on to your infant⁴).

Begin or continue to get at least 400 micrograms of folic acid by taking vitamin supplements every day to reduce your child's risk of neural tube defects. In the United States, enriched grain products such as bread, cereal, pasta, and other grain-based foods are fortified with folic acid. A related form, called folate, occurs naturally in leafy, green vegetables and orange juice, but folate is not absorbed as well as folic acid.² Also, it can be difficult to get all the folic acid you need from food alone.³ Most prenatal vitamins contain 400 micrograms of folic acid.⁴ If you have had a child with an NTD before, taking a larger daily dose of folic acid (4 mg) before and during early pregnancy can reduce the risk for recurrence in a subsequent pregnancy.

Drinking alcohol, smoking, and taking drugs during pregnancy can increase your child's risk for problems such as fetal alcohol spectrum disorders (FASDs), sudden infant death syndrome (SIDS), and other problems.^5,6

FASDs are a variety of effects on the fetus that result from the mother drinking alcohol during pregnancy. The effects range from mild to severe, and they include intellectual and developmental disabilities; behavior problems; abnormal facial features; and disorders of the heart, kidneys, bones, and hearing. FASDs last a lifetime although early intervention services can help improve a child's development. FASDs are completely preventable: If a woman does not drink alcohol while she is pregnant, her child will not have an FASD.⁷ Currently, research shows that there is no safe amount of alcohol to drink while pregnant. According to one recent study supported by the NIH, infants can suffer long-term developmental problems even with low levels of prenatal alcohol exposure.⁸

Other research shows that smoking tobacco, smoking marijuana, exposure to second-hand smoke, and taking drugs during pregnancy can also harm the fetus and affect infant health. One study showed that smoking tobacco or marijuana and using illegal drugs doubled or even tripled the risk of stillbirth, fetal death after 20 weeks of pregnancy.⁹ Likewise, drinking alcohol, smoking tobacco, and exposure to second-hand smoke during pregnancy increases the risk of SIDS, the sudden, unexplained death of an infant younger than 1 year old.¹⁰ Research also shows that smoking marijuana during pregnancy can interfere with normal brain development in the fetus, possibly causing long-term problems.¹¹ For more information, visit https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/
substance-use-while-pregnant-breastfeeding.

Your health care provider can be a source of help if you find it hard to quit smoking or drinking on your own. You can also visit http://smokefree.gov/ for plans and information about quitting smoking. The Rethinking Drinking website provides resources and information related to quitting alcohol use. The Substance Abuse and Mental Health Services Administration (SAMHSA) offers a services locator through its website at https://findtreatment.samhsa.gov/. SAMHSA also has a confidential hotline through which people can find assistance: 1-800-662-HELP (4357).

According to the CDC, most women take at least one medication during pregnancy.¹² The majority of medications have not been specifically studied for use in pregnancy. Talk to your health care provider about over-the-counter and prescription medications and herbal and vitamin supplements. Certain medications to treat acne and epilepsy and some dietary or herbal supplements can harm the fetus during pregnancy.

Taking prescription pain medications, specifically opioids, during pregnancy can pose serious risks to the fetus. Taking these medications during pregnancy doubles or even triples the risk for stillbirth.⁹ If taken regularly during pregnancy, the baby may go through withdrawal after birth, a situation called neonatal abstinence syndrome (NAS). Babies with NAS face a variety of symptoms and problems, some of them severe.¹³ The best way to protect your baby from these problems is to stop taking these medications during pregnancy.

During pregnancy, exposure to radiation, pesticides, some metals, and certain chemicals can cause birth defects, premature birth, and miscarriage.¹⁴ If you're not sure if something might be harmful to you or your fetus, avoid contact with it until you check with your health care provider.

If you work in a job on a farm, a dry cleaner, a factory, a nail or hair salon, you might be around or come into contact with potentially harmful substances. Talk to your health care provider and your employer about how you can protect yourself before and during pregnancy. You may need extra protection at work or a change in your job duties to stay safe.¹⁴

A few examples of exposures that are known to be toxic to the developing fetus are:

Lead: Lead is a metal that may be present in house paint, dust, and garden soil. Any home built before 1978 may have lead paint. Exposure can occur when removing paint in old buildings (or if the paint is peeling) and working in some jobs (for example, manufacturing automotive batteries). Lead is also present in some well water and in water that travels through lead pipes. High levels of lead during pregnancy can cause miscarriage, stillbirth, low birth weight, and premature delivery, as well as learning and behavior problems for the child.¹⁵ Women who had exposure to lead in the past should have1 their blood levels checked before and during pregnancy.¹⁵ Call the National Lead Information Center for information about how to prevent exposure to lead at: 800-424-LEAD.

Radiation: Radiation is energy that travels through space. It can be in the form of X-rays, radio waves, heat, or light, or it can come from "radioactive" materials like dust, metals, or liquids that give off energy called radioactivity. Low exposures to radiation from natural sources (such as from the sun) or from microwave ovens or routine medical X-rays are generally not harmful. Because the fetus is inside the mother, it is partially protected from radiation's effects.^14,16 Pregnant women or women who might be pregnant should make sure their dentists and doctors are aware of this so appropriate precautions can be taken with medical scans (X-rays or CT scans) or treatments that involve radiation.¹⁴ Pregnant women who may be exposed to radiation in the workplace should speak with their employer and health care provider to make sure the environment is safe during their pregnancy. Nuclear or radiation accidents, while rare, can cause high radiation exposures that are extremely dangerous, especially to the developing fetus.

Solvents: Solvents are chemicals that dissolve other substances. Solvents include alcohols, degreasers, and paint thinners. Some solvents give off fumes or can be absorbed through the skin and can cause severe health problems. During pregnancy, being in contact with solvents, especially if you work with them, can be harmful. Solvents may lead to miscarriage, slow the growth of the fetus, or cause preterm birth and birth defects.¹⁴ Pregnant women who may be exposed to solvents in the workplace should speak with their employer and health care provider to make sure the environment is safe during their pregnancy.¹⁷ Whenever you use solvents, be sure to do so in a well-ventilated area, wear safety clothes (such as gloves and a face mask), and avoid eating and drinking in the work area.¹⁴

Many chemicals are commonly found in the blood and body fluids of pregnant women and their infants. However, much remains unknown about the effects of fetal exposure to chemicals.¹⁸ It's best to be cautious about chemical exposure when you are planning to get pregnant or if you are pregnant. Talk to your health care provider if you live or work in or near a toxic environment.¹⁷

Choose a variety of fruits, vegetables, whole grains, and low-fat dairy products to help ensure the developing fetus gets all the nutrients it needs. Make sure you also drink plenty of water. An online tool called the Daily Checklist for Moms can help you plan your meals so that you get the right foods in the right amounts according to your personal characteristics and your stage of pregnancy.

Read Nutrition During Pregnancy FAQs  (PDF – 72.1 KB) from the American College of Obstetricians and Gynecologists to learn more about how much you should eat during pregnancy, the nutrients you need, and how much caffeine is safe to drink.

Avoid certain foods such as raw fish, undercooked meat, deli meat, and unpasteurized cheeses (for example, certain types of feta, bleu cheese, and Mexican-style soft cheeses).¹⁹ Always check the label to make sure the cheese is pasteurized.

Some pregnant women are concerned about the amount of fish they can safely consume. Certain fish contain methylmercury, when certain bacteria cause a chemical change in metallic mercury. Methylmercury is found in foods that fish eat, and it remains in the fish's body after it is eaten. Methylmercury in fish eaten by pregnant women can harm a fetus's developing nervous system.

According to the U.S. Food and Drug Administration (FDA), pregnant women can eat up to 12 ounces a week of fish and shellfish that have low levels of methylmercury (salmon, canned light tuna, and shrimp). Albacore ("white") tuna has more methylmercury than canned light tuna; pregnant women should consume 6 ounces or less in a week. Avoid fish with high levels of methylmercury (swordfish, king mackerel, and shark). For more information on methylmercury and pregnancy, see the FDA Food Safety for Moms-to-Be.¹⁹

Some studies suggest that too much caffeine can increase the risk of miscarriage. Talk to your health care provider about the amount of caffeine you get from coffee, tea, or soda. Your health care provider might suggest a limit of 200 milligrams (the amount in about one 12-ounce cup of coffee) per day. Keep in mind, though, that some of the foods you eat, including chocolate, also contain caffeine and contribute to the total amount you consume each day.²⁰

Most women can continue regular levels of physical activity throughout pregnancy. Regular physical activity can help you feel better, sleep better, and prepare your body for birth. After your child is born, it can help get you back to your pre-pregnancy shape more quickly.²¹ Talk to your health care provider about the amount and type of physical activity that is right for you.

Gaining too much or too little weight during pregnancy increases the risk of problems for both the mother and the infant. Following a healthy diet and getting regular physical activity can help you stay within the recommended weight gain guidelines set by the Institute of Medicine.

The amount of weight you should gain during pregnancy depends on your pre-pregnancy weight and body mass index (BMI), which is your weight in kilograms divided by the square of your height in meters (kg/m²). The following guidelines are for women who are pregnant with one fetus. The recommendations are different if you are pregnant with more than one fetus (such as twins).^22,23

• Women who are underweight (BMI less than 18.5) should gain between 28 and 40 pounds.
• Women at a normal weight (BMI between 18.5 and 24.9) should gain between 25 and 35 pounds.
• Overweight women (BMI 25 to 29.9) should gain between 15 and 25 pounds.
• Obese women (BMI more than 30) should gain between 11 and 20 pounds.

In a recent NICHD study of more than 8,000 pregnant women, 73% gained more than the recommended amount of weight. The study found that excessive weight gain during pregnancy increases the risk for gestational high blood pressure, cesarean section, and large-for-gestational-age infants.²⁴

Talk to your health care provider about the right amount of weight gain for you based on your pre-pregnancy weight.

Iron-deficiency anemia—when the body doesn't have enough iron—is common during pregnancy and is associated with preterm birth and low birth weight. Your health care provider may screen you for iron-deficiency anemia and, if you have it, may recommend iron supplements.²⁵ Your health care provider may also recommend a vitamin B12 supplement if you are a vegan.^26,27 (Vegetarians normally get enough vitamin B12 by eating eggs and dairy products.)

Your gums are more likely to become inflamed or infected because of hormonal changes and increased blood flow during pregnancy.²⁸ Make sure you tell your dentist if you think you could be pregnant, but keeping up your regularly scheduled checkups is important. Some women may fear getting dental work during pregnancy, but a 2006 study and 2011 follow-up study showed no increase in preterm births or other adverse outcomes for pregnant women who received dental care.²⁹

Certain infections can affect pregnancy or the developing fetus. It's important to take steps to prevent such infections or get medical treatment before or during pregnancy.

Vaccinations can protect against many infections that can affect the mother's health, the pregnancy, the fetus, and even her newborn child. Some vaccines need to be given before pregnancy, so it's a good idea to review your vaccination history with your health care provider as part of your pre-pregnancy care. The Centers for Disease Control and Prevention provides recommendations about timing of vaccinations to help ensure a healthy pregnancy.

Learn more about how infections can affect pregnancy and which infections can cause problems during pregnancy.

Your first prenatal visit will probably be scheduled sometime after your eighth week of pregnancy. Most health care providers won't schedule a visit any earlier unless you have a medical condition, have had problems with a pregnancy in the past, or have symptoms such as spotting or bleeding, stomach pain, or severe nausea and vomiting.¹

You've probably heard pregnancy discussed in terms of months and trimesters (units of about 3 months). Your health care provider and health information might use weeks instead. Here's a chart that can help you understand pregnancy stages in terms of trimesters, months, and weeks.

Because your first visit will be one of your longest, allow plenty of time.

During the visit, you can expect your health care provider to do the following:¹

• Answer your questions. This is a great time to ask questions and share any concerns you may have. Keep a running list for your visit.
• Check your urine sample for infection and to confirm your pregnancy.
• Check your blood pressure, weight, and height.
• Calculate your due date based on your last menstrual cycle and ultrasound exam.
• Ask about your health, including previous conditions, surgeries, or pregnancies.
• Ask about your family health and genetic history.
• Ask about your lifestyle, including whether you smoke, drink, or take drugs, and whether you exercise regularly.
• Ask about your stress level.
• Perform prenatal blood tests to do the following:
• Determine your blood type and Rh (Rhesus) factor. Rh factor refers to a protein found on red blood cells. If the mother is Rh negative (lacks the protein) and the father is Rh positive (has the protein), the pregnancy requires a special level of care.²
• Do a blood count (e.g., hemoglobin, hematocrit).
• Test for hepatitis B, HIV, rubella, and syphilis.
• Do a complete physical exam, including a pelvic exam, and cultures for gonorrhea and chlamydia.
• Do a Pap test or test for human papillomavirus (HPV) or both to screen for cervical cancer and infection with HPV, which can increase risk for cervical cancer. The timing of these tests depends on the schedule recommended by your health care provider.
• Do an ultrasound test, depending on the week of pregnancy.
• Offer genetic testing: screening for Down syndrome and other chromosomal problems, cystic fibrosis, other specialized testing depending on history.

If your pregnancy is healthy, your health care provider will set up a regular schedule for visits that will probably look about like this:¹

As your pregnancy progresses, your prenatal visits will vary greatly. During most visits, you can expect your health care provider to do the following:

• Check your blood pressure.
• Measure your weight gain.
• Measure your abdomen to check your developing infant's growth—"fundal height" (once you begin to "show").
• Check the fetal heart rate.
• Check your hands and feet for swelling.
• Feel your abdomen to find the fetus's position (later in pregnancy).
• Do tests, such as blood tests or an ultrasound exam.

Talk to you about your questions or concerns. It's a good idea to write down your questions and bring them with you.

Several of these visits will include special tests to check for gestational diabetes (usually between 24 and 28 weeks)³ and other conditions, depending on your age and family history.

In addition, the Centers for Disease Control and Prevention and the American Academy of Pediatrics released new vaccine guidelines for 2013, including a recommendation for pregnant women to receive a booster of whooping cough (pertussis) vaccine. The guidelines recommend the shot be given between 27 and 36 weeks of pregnancy.⁴

Glucose challenge screening. Usually given between 24 and 28 weeks of pregnancy, this screening assesses your risk for gestational diabetes. You will consume a sugary drink and get a blood test 1 hour later to measure your blood sugar levels. If you are at high risk—for example, if you have a family history of diabetes, are obese, had a large baby in a previous pregnancy, or are having twins—you should discuss this with your health care provider get a test for blood glucose earlier in your pregnancy.

Group B streptococcus (pronounced STREP-tuh-KOK-uhss) infection screening. This test is performed between 35 and 37 weeks of pregnancy to look for bacteria (GBS) that can cause pneumonia or other serious infections in your infant. Swabs will be used to take cells from your vagina and rectum. Women who test positive for GBS will need antibiotics when in labor.

Ultrasound exam. You will likely have an ultrasound exam between 18 and 20 weeks of pregnancy to check for any problems with the developing fetus. During an ultrasound exam, gel is spread on your belly and a special tool is moved over it to create a "picture" of the fetus on a monitor.

Urine test. At each prenatal visit, you will give a urine sample, which will be tested for signs of diabetes, urinary tract infections, and preeclampsia.

Nuchal translucency (pronounced NOO-kuhl trans-LOO-sen-see) screening. This screening test uses ultrasonography to measure the thickness of the back of the fetus's neck between 11 and 14 weeks. This information, combined with the mother's age and the results of the serum screen, helps health care providers determine the fetus's potential risk for chromosomal abnormalities and other problems.

First trimester screen. Blood is drawn to test for PAPP-A and free beta-hCG (or hCG) and may be combined with performing a nuchal translucency ultrasound. This test will provide the risk for Down syndrome as well as other chromosomal problems.

Maternal serum screen (also called quad screen, triple test, triple screen, multiple marker screen, or AFP). Blood is drawn to measure the levels of certain substances that determine the risk of the fetus having chromosomal abnormalities and NTDs. This screening test is done between 15 and 20 weeks of pregnancy.

Chorionic villus (pronounced KOR-ee-ON-ihk VIL-uhss) sampling (CVS). If your fetus is at risk for a chromosomal defect or other genetic disorders, your doctor may recommend this test when you are between 10 and 13 weeks pregnant. In this test, a needle is inserted through the cervix or the abdomen to remove a small sample of cells from the placenta.

Amniocentesis (pronounced AM-nee-oh-sen-TEE-sis). Given between 15 and 20 weeks of pregnancy, this test is used to diagnose chromosomal disorders, such as Down syndrome and your infant's risk for NTDs, such as spina bifida. After a local anesthetic is given, a thin needle is inserted into the abdomen to draw out a small amount of amniotic fluid and cells from the sac surrounding the fetus. The fluid is sent to a lab for testing.²

Cell-free fetal DNA. A new, noninvasive test uses the mother's blood to look for increased amounts of material from chromosomes 21, 18, and 13. This test can be given as early as 10 weeks to women whose age, family history, or standard screening results put them at higher risk for having a child with a chromosome disorder. The test is not recommended for women who are at low risk or are carrying multiple fetuses.³

Carrier screening for cystic fibrosis (CF). A blood or saliva test determines if you and your partner are carriers for this genetic disease that affects breathing and digestion. Both parents must be a carrier for their child to get CF.

Glucose tolerance test. If the 1-hour glucose challenge screening is above a certain level, your health care provider may order this test. You will fast for at least 8 hours before the test. Your blood is drawn to test your "fasting blood glucose level." You will consume a sugary drink, and your blood will be taken every hour for 3 hours to see how your body reacts to the sugar. You may then be diagnosed with gestational diabetes.

Non-stress test. This test is performed in the third trimester (28 weeks or later) to monitor the fetus's health. A belt placed around your belly measures the fetal heart rate while the fetus is at rest and while the fetus is moving or kicking. This test can determine if the fetus is getting enough oxygen.

Biophysical profile (BPP). This test, given in the third trimester of pregnancy, monitors the fetus's breathing, movement, muscle tone, and heart rate as well as the amount of amniotic fluid to determine fetal well-being. The BPP includes an ultrasound test and a non-stress test.5

Anemia occurs when your red blood cell count (hemoglobin or hematocrit) is low. Iron deficiency anemia is the most common type of anemia. Iron is part of the hemoglobin that allows blood to carry oxygen. Pregnant women need more iron than normal for the increased amount of blood in their body and for their developing child.² Symptoms of iron deficiency include feeling tired or weak, looking pale, feeling faint, or experiencing shortness of breath. Your health care provider may recommend iron and folic acid supplements.³

Gestational diabetes occurs when blood sugar levels are found to be too high during pregnancy. The exact number of women affected by gestational diabetes is unknown because of different diagnostic criteria and risk profiles.⁴ Most often the condition is discovered using a two-step procedure: screening with the glucose challenge screening test around 24 to 28 weeks of pregnancy, followed by a diagnostic test called the oral glucose tolerance test. Gestational diabetes increases the risk of a baby that is too large (macrosomia), preeclampsia (pronounced pree-i-KLAMP-see-uh, a condition marked by a sudden increase in a pregnant woman's blood pressure along with the presence of protein in the urine after the 20th week of pregnancy), and cesarean birth. Treatment includes controlling blood sugar levels through a healthy diet and exercise, and through medication if blood sugar values remain high.⁵

Many people are familiar with the phrase "postpartum depression," meaning depression that occurs after the birth of a baby. But we now know that it's not just during the postpartum period, and it's not just depression.

Women experience depression and anxiety, as well as other mental health conditions, during pregnancy and after the baby is born. These conditions can have significant effects on the health of the mother and her child.

The NICHD-led Moms' Mental Health Matters initiative is designed to educate consumers and health care providers about who is at risk for depression and anxiety during and after pregnancy, the signs of these problems, and how to get help. The initiative also includes Information for Partners, Family, and Friends on ways to help.

There is no single cause of depression or anxiety during and after pregnancy, but hormonal changes, stress, family history, and changes in brain chemistry or structure may all play a role.⁶ Women who have complications during pregnancy are at higher risk for postpartum depression than are women who do not have complications.⁷

Depression can harm the developing fetus if you do not take care of yourself during pregnancy, including attending regular prenatal visits and avoiding alcohol and tobacco smoke. Talk to your health care provider if you feel overwhelmed, sad, or anxious. Even though they are serious conditions, depression and anxiety are treatable.

Possible problems in the fetus include decreased movement after 28 weeks of pregnancy and being measured as smaller than normal. These pregnancies often require closer follow-up including more testing such as ultrasound exams, non-stress testing and biophysical profiles as well as possible early delivery.

Pregnant women who develop high blood pressure will need to be monitored closely for preeclampsia.

Infections, including some sexually transmitted infections (STIs), may occur during pregnancy and/or delivery and may lead to complications for the pregnant woman, the pregnancy, and the baby after delivery. Learn more about how infections can affect pregnancy and which infections can cause problems during pregnancy. For the latest information on COVID-19 and pregnancy, visit CDC at https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnant-people.html.

(Pronounced HEYE-pur-EM-uh-suhss grav-uh-DAR-uhm). Some women experience severe, persistent nausea and vomiting during pregnancy beyond the typical "morning sickness." Medication may be prescribed to help with the nausea. Women with hyperemesis gravidarum may need hospitalization to get the fluids and nutrients they need through a tube in their veins. Often, the condition lessens by the 20th week of pregnancy.

Pregnancy loss from natural causes before the 20th week is considered a miscarriage. It is hard to estimate exactly how many pregnancies end in miscarriage because they may occur before a woman even knows she is pregnant.⁸ The most common cause of first trimester miscarriage is chromosomal problems. Symptoms can include cramping or bleeding. Spotting early in pregnancy is common and does not mean that a miscarriage will occur.

This condition occurs when the placenta covers part of the opening of the cervix inside the uterus. It can cause painless bleeding during the second and third trimesters. The health care provider may recommend bed rest. Hospitalization may be required if bleeding is heavy or if it continues. Placental problems may affect how the baby is delivered.

In some women, the placenta separates from the inner uterine wall. This separation, or abruption, can be mild, moderate, or severe. If severe, the fetus cannot get the oxygen and nutrients needed to survive. Placental abruption can cause bleeding, cramping, or uterine tenderness. Treatment depends on the severity of the abruption and how far along the pregnancy is. Severe cases may require early delivery.

Preeclampsia is a quick or sudden onset of high blood pressure after the 20th week of pregnancy. This condition causes high blood pressure, swelling of the hands and face, abdominal pain, blurred vision, dizziness, and headaches. In some cases, seizures can occur—this is called eclampsia (pronounced ih-KLAMP-see-uh). The only definite cure for preeclampsia and eclampsia is to deliver the baby. If this would result in a preterm birth, then the maternal and fetal risks and benefits of delivery need to be balanced with the risks associated with the infant being born prematurely.

Infants do best if they are born after 39 or 40 weeks of pregnancy (full term). The fetus's lungs, liver, and brain go through a crucial period of growth between 37 weeks and 39 weeks of pregnancy.

Going into labor before 37 weeks of pregnancy is a major risk factor for complications for the infant and for future preterm births for the mother. Sometimes, when there is a health risk to the mother or baby, planned deliveries before 39 weeks are necessary. However, in a healthy pregnancy, it's best to wait until at least 39 weeks. Learn more about why it's worth it to wait until at least 39 weeks to deliver for healthy pregnancies.

NICHD conducts and supports many studies that confirm and reinforce the importance of pre-pregnancy care and prenatal care for a healthy pregnancy. Several organizational units focus their research on ways that pre-pregnancy and prenatal care can reduce complications during pregnancy and reduce the effects of environmental and lifestyle factors on the developing fetus.

The Pregnancy and Perinatology Branch (PPB) seeks to extend and enhance research in prevention of preterm birth, preeclampsia, fetal surgery, stillbirth, periconceptional exposure to alcohol, sudden infant death syndrome (SIDS), health disparities, and perinatal genetics. PPB research related to pre-pregnancy care and prenatal care includes the following:

• Supporting the Lifestyle Interventions for Expectant Moms (LIFE-Moms) Consortium, along with the National Institute of Diabetes and Digestive and Kidney Disease; the National Heart, Lung, and Blood Institute; and the National Center for Complementary and Alternative Medicine. The LIFE-Moms Consortium is conducting clinical trials of lifestyle interventions, for example, changes in diet and physical activity, among overweight and obese pregnant women to help them gain the appropriate amount of weight during pregnancy and improve the health of both mother and baby after delivery.
• Examining the causes of SIDS, stillbirth, fetal alcohol spectrum disorders, and other adverse outcomes related to prenatal exposure to alcohol. The Safe Passage Study, part of the Prenatal Alcohol and SIDS and Stillbirth (PASS) Network, seeks to decrease fetal and infant mortality and improve child health in communities at high risk for prenatal maternal consumption of alcohol.
• Supporting clinical trials in maternal-fetal medicine and obstetrics, particularly with respect to the continuing problem of preterm birth. The trials are conducted through the Maternal Fetal Medicine Units (MFMU) Network, which is composed of 14 sites across the United States and a data coordinating center. Current studies include a randomized clinical trial of antibodies from pooled human plasma for preventing congenital cytomegalovirus (CMV) and an observational trial of hepatitis C in pregnancy
• Examining how community, family, and individual level influences interact with biological influences to affect allostatic load (physiologic consequences as a result of stress), and how resiliency factors operate to alter allostatic load. The Community Child Health Network (CCHN) study studies the effects of allostatic load on perinatal outcomes and on health disparities in pregnancy outcomes.
• Studying the causes of stillbirth, improving the reporting of stillbirth, and developing preventive interventions for stillbirth through the Stillbirth Collaborative Research Network (SCRN).
• Studying the mechanism and prediction of adverse pregnancy outcomes in nulliparous women (women in their first pregnancy). The aim of the Nulliparous Pregnancy Outcomes Study Monitoring Mothers-to-be (nuMoM2b) study is to determine factors/tests in the first and early second trimesters that will identify women at the highest risk for preterm birth, preeclampsia, fetal growth restriction, and stillbirth in 10,000 women. In addition, a study of sleep disordered breathing during pregnancy is being conducted.

The Perinatal and Obstetrical Research Group, within the Division or Intramural Research, examines the genetic and environmental etiologies and mechanisms of spontaneous preterm birth. Using state-of-the-art molecular approaches, such as genome-wide association studies and global serum protein profiling, the Group aims to identify new biomarkers that increase the risk of a preterm delivery and to delineate molecular mechanisms responsible for a preterm birth.

The Division of Population Health Research (DiPHR) conducts studies on the following:

• Neural Tube Defects (NTDs). The Division currently supports studies examining the role of abnormal folate metabolism in NTDs. Researchers are also studying the role of genetics in spina bifida and other NTDs.
• Alcohol use during pregnancy. Researchers are studying the mechanisms by which prenatal exposure to alcohol causes slow growth in infants and children.
• Leptin signaling. Leptin signaling is being studied as the mechanism by which maternal obesity influences the risk for spina bifida.
• Measurement of fetal growth as a critical part of a healthy pregnancy, through the NICHD Fetal Growth Studies—Singletons and Twins (see PMID: 26410205 and PMID: 27143399) and the Fetal 3D Study.
• The relationship between high levels of folic acid and vitamin B12. Increased folate can mask vitamin B12 deficiencies. Researchers studied the effects of consuming foods fortified with folate on people with low levels of vitamin B12.
• Investigating the long-term health implications of pregnancy and neonatal complications through the Collaborative Perinatal Project Mortality Linkage Study.

The Obstetric and Pediatric Pharmacology and Therapeutics Branch promotes research to improve the safety and efficacy of pharmaceuticals and to ensure centralization and coordination of research, clinical trials, and drug development activities for obstetric and pediatric populations. Much of this work is conducted through the Maternal and Pediatric Precision in Therapeutics (MPRINT) Hub, which the Branch funds.

The Maternal and Pediatric Infectious Disease Branch (MPIDB) supports both domestic and international research into the epidemiology, natural history, pathogenesis, transmission, treatment, and prevention of HIV infection and its complications in infants, children, adolescents, pregnant women, mothers, women of childbearing age, and the family unit as a whole. Branch-supported research efforts seek to enhance knowledge about the elevated risk of transmitting HIV to infants among women who acquire HIV during pregnancy.

In addition, the MPIDB supports and conducts research into other important infectious diseases. For example, NICHD, along with several other NIH Institutes, is prioritizing Zika virus research as it relates to the mother-infant dyad and the effects of infection. The Branch is supporting a wide range of research activities, including the trans-NIH Zika in Infants and Pregnancy (ZIP) study, a large epidemiologic study of pregnant women in areas affected by Zika virus. Another observational study of pregnant women in Brazil will help improve understanding of the effects of Zika virus infection on reproductive health and the developing fetus.

The Intellectual and Developmental Disabilities Branch supports studies focused on developing safe and accurate techniques for making prenatal diagnoses for various intellectual and developmental disabilities and other conditions that might have long-term effects on health and well-being.

To better understand pre-pregnancy care and prenatal care and how they can promote a healthy pregnancy, NICHD supports a variety of other activities. Some of these activities are managed through the components listed above; others are part of NIH-wide or collaborative efforts in which NICHD participates. Some of these activities are listed below.

• The Congenital Anomalies Research Group is a multicenter, multidisciplinary group led by NICHD's DIPHR to investigate the etiology of congenital anomalies, particularly neural tube defects. The National Human Genome Research Institute, the Health Research Board of Ireland, and the Department of Biochemistry, Trinity College, Dublin, also collaborate on this effort.
• The Human Placenta Project is a collaborative research initiative launched by NICHD to understand and monitor the development of the human placenta during pregnancy. The project will support the development of new technologies to assess the health of the placenta as it grows and matures, with the ultimate goal of improving the health of mothers and children.
• The Maternal-Fetal Surgery Network was created in 2001 through the PPB to investigate surgical treatment for spina bifida, specifically in utero surgery as compared with postnatal surgery for myelomeningocele.
• The Reproductive Medicine Network, funded through the NICHD Fertility and Infertility (FI) Branch, currently leads several clinical trials to determine whether specific pre-pregnancy care activities in women with polycystic ovary syndrome can help them conceive and deliver a healthy infant.
• The Maternal and Pediatric Precision in Therapeutics (MPRINT) Hub, supported by the Obstetric and Pediatric Pharmacology and Therapeutics Branch, provides the infrastructure and expertise needed to test therapeutic drugs during pregnancy. It allows researchers to conduct safe, technically sophisticated, and complex studies that will help clinicians protect women's health, improve birth outcomes, and reduce infant mortality.
• NICHD created the National Child and Maternal Health Education Program (NCMHEP) in 2008 to provide a forum for reviewing, translating, and disseminating new research in maternal and child health. Current NCMHEP initiatives include:
  • Is It Worth It?—the Initiative to Reduce Elective Deliveries Before 39 Weeks of Pregnancy
  • The Know Your Terms Initiative
  • The Moms' Mental Health Matters initiative to raise awareness about depression and anxiety during and after pregnancy