Should I take iron and folic acid supplements during pregnancy?
Is this a trick question? The easy part to answer is regarding folic acid; all women should take 400 mcg of folic acid daily from the time they think about getting pregnant through at least the first twelve weeks of pregnancy, to prevent neural tube defects in the fetus (these can lead to serious birth defects such as spina bifida). Enough said about that. The tricky part is regarding iron. For most healthy women who live in the developed world and eat a balanced diet with a focus on iron-rich foods (see below), iron supplements are not necessary and may even be harmful.
There is current controversy about what constitutes a “normal” blood count or hematocrit during pregnancy. Certainly, it is lower than a woman’s normal non-pregnant hematocrit, about 37-40%. During early pregnancy, the blood is diluted with additional fluid, and so the red blood cells, which carry the iron, constitute a smaller fraction of the whole blood. As the bone marrow is triggered to make more red blood cells, they catch up, add more red blood cells to the diluted fluid, and the hematocrit rises again later in pregnancy. What we used to think of as “anemia” during pregnancy may actually be a normal physiological process. Thinner blood may cross the placenta and get to the baby more easily. We may be making things worse, not better, by trying to get women’s hematocrits back up to the normal non-pregnant values.
Almost all pregnant women will show a decrease in the lab tests that relate to iron stores; for most of them, this is not harmful and be even be beneficial. For years, pregnant women have routinely been prescribed iron supplements on the basis of their CBC (complete blood count), without taking into account their diet. But most women don’t need this extra iron, and they certainly don’t need the problems that it may cause. Additional iron can be gotten with iron-rich foods, most of which we should be eating every day: red meat, clams and mussels, other fish, dark green leafy vegetables (especially kale, collards, mustard greens, chard – easy to grow in your garden!), orange vegetables like squash, and dried fruits (prunes, raisins, figs). Cast iron skillets are good for adding iron to your diet; as you cook in them, a tiny amount of the iron leaches off into the food. Traditionally, African-American women in the southern US frequently seemed “immune” to iron deficiency, but it turned out that they fried their food in an iron skillet and served it up it with a large serving of collard or mustard greens. Also, most prenatal vitamins (which, arguably, you don’t need either) usually contains the iron equivalent of a single iron tablet.
Nonetheless, there are some women who have true iron-deficiency anemia, who do not respond to an increase in iron-rich foods but whose lab results continue to drift downward and who become symptomatic. They may experience easy fatigue, palpitations or shortness of breath, pallor, weakness, headache, light-headedness, or cold hands and feet. These women do need more iron than their diets can provide. They may have to take an iron supplement up to three times a day. If you are one of these women, discuss your options with your midwife or physician to determine which type of iron supplementation will be right for you, considering your diet and general health. The most common and the cheapest iron supplement is iron (or ferrous) sulfate, available over the counter and cheaply at any pharmacy or grocery. One or two tablets a day taken with citrus juice or with water will improve the blood count over several months. However, for some women, these tablets can be harsh on the stomach and cause constipation, or make existing constipation worse.
If you need additional iron and cannot tolerate iron sulfate tablets, there are several alternatives. Iron gluconate is easier on the stomach, and there are some time-released versions. These are more expensive, of course, than iron sulfate tablets, and usually require a prescription. Finally, there is Floradix, a liquid herbal supplement from Germany which seems to work for women who cannot tolerate the other options and can’t get their iron stores up with food. It seems to work very well. Taking Floradix twice a day should build your iron stores at about the same rate that iron tablets would, with no gastric side effects. Floradix contains less iron than these supplements, but it is 25% absorbed compared to 2-10% for the tablets. It also contains B vitamins and vitamin C which enhance absorption, herbal extracts to increase digestion, and fruit juices to ensure proper stomach acidity. A 20mL dose of Floradix will deliver15 mg of iron; taking it twice a day should definitely improve your iron stores.
Unfortunately, there is an almost universal propensity among obstetricians and many midwives to treat all women with iron during pregnancy. However, the decision to use iron supplementation routinely in normal women may not be helpful and may be harmful. According to a 2012 Cochrane review, “The use of iron or iron and folic acid supplements was associated with a reduced risk of anaemia and iron deficiency during pregnancy and of giving birth to low birthweight babies. Daily iron supplementation was, however, associated with the women having side effects such as constipation and other gastrointestinal effects including nausea, vomiting and diarrhoea and an increased risk of high haemoglobin (Hb) concentrations at term. This may be harmful to mothers and babies and is associated with late pregnancy hypertension, pre-eclampsia and pregnancy complications.” – See more at http://summaries.cochrane.org/CD004736/effects-and-safety-of-preventive-oral-iron-or-iron–folic-acid-supplementation-for-women-during-pregnancy#sthash.CUazfd9J.dpuf
So, to summarize a straight answer to a trick question: all women should take daily folic acid 400 mcg from the time they anticipate a possible pregnancy through conception and at least the first twelve weeks; most normal healthy women do not need more iron than they can get from a balanced diet including ir0n-rich foods, so do not need to take a supplement; however, a small percentage of women who have a significant intractable iron-deficiency anemia do need to take supplemental iron in some form.