Most dietary guidelines are very generic, but the Higgins Intervention Method has specific plans for meeting the special requirements of mothers with different nutritional needs. I like the ability this method gives to really personalize the recommendations and the ability it gives me to quantify the nutritional needs rather than just saying “eat more”.

If you are working with a pregnant teen, she needs more than the standard prenatal calories and protein.  This is because her body is still growing, and she needs to eat enough to support both her growth and the growth of her baby. So you would need to add the 300 additional calories a day to the higher values of protein and calories of a teen.

Mothers who are underweight will need to eat an increased protein and calorie diet. However, the Higgins Intervention Method recommends increasing it only for the number of weeks needed to add the weight to make up for the deficit. So if she were 10 pounds underweight, adjust her diet so she gains an extra 1 pound per week for 10 weeks (or 1/2 a pound a week for 20 weeks).

Mothers who are undernourished are determined by the protein intake on the Higgins Intervention Method. To calculate the protein deficit, you would compare her protein intake to the normal pregnancy requirements.  To correct for this add as additional daily protein the amount she is deficient and increase her caloric intake 10 calories for each gram of protein she is deficient.

Vegetarian women do not need any different guidelines.  They will simply choose animal sources for their food.  The biggest struggle, which may not be a struggle at all, will be getting enough protein since vegetable sources of protein are not as protein dense as animal sources. If she has trouble consuming enough calories to get adequate protein she can consider supplementing with any number of a variety of protein supplements.

Lactating women need even more calories than pregnant women.  The 300 calorie increase becomes 500 calories.  All the principles of good nutrition still apply.

Vitamins and minerals are referred to as micronutrients.  They do not contribute calories to the diet, but do play an important role in cellular function.  Remember cells?  They make up your entire body and are responsible for your body being able to stay healthy.

I personally have never been a fan of vitamin and mineral supplementation.  I am a purist in that I believe the diet should be adjusted before a pill is taken. But I do understand there are limits to what a woman is able to eat from time to time.

Allow me to use myself as an example. Over the last two months since school began I have found myself becoming more and more tired and unable to focus.  My stress level was increasing and my schedule was really out of control some weeks.  Balancing classes, studying, clincials and family left little time for cooking and forget about shopping.  I was relying on what I could pack in the morning, selected from what my husband chose to purchase.

Two weeks ago I made two changes.  First, I decided to keep a water bottle on the counter when I am home to remind me to keep drinking water.  Secondly, I started taking a multivitamin every day.  It took a couple days, but I started feeling better. I was sold.  Because of the temporary and unique demands on my body and time right now, I will continue to use a multivitamin supplement.

Honestly, I don’t think that conflicts with my basic theory about supplementation.  Supplements are available for the unique situations that prevent a person from achieving optimum nutrition from their diet. So how does this relate to pregnant women?

Think first trimester and the most common pregnancy complaint – nausea and vomiting.  This can prevent a woman from maintaining her normally healthy diet.  Some women experience food aversions throughout their entire pregnancy.  Again, these can make it difficult to maintain a normal healthy diet.  Supplementation can help by providing a little insurance (as long as she can keep the vitamins down).

Another common pregnancy complaint is fatigue.  In many women this is linked to anemia caused by low iron stores.  Pregnancy increases your bodies need for iron, and if your iron stores where not optimum to begin with (as is common for about 40% of American women), you can experience a mild to moderate anemia.  This can be especially true if this pregnancy happened quickly after a previous pregnancy.  Iron supplementation can help to manage this problem.

Though fiber is not a nutrient, it is necessary in the diet.  Most Americans do not consume the recommended 25-30 grams of fiber a day. This can lead to problems with constipation.  Since pregnant women are more likely to experience constipation, the inability to consume adequate fiber can compound a common pregnancy problem.  Women taking iron pills may increase their risk of constipation.  Fiber supplementation can be a temporary help during this time of increased need.

Folic Acid supplementation is recommended for all women of childbearing age.  Why?  Because deficiency of this nutrient can actually cause harm to your baby in the form of neural tube defects.  Unfortunately, by the time most women discover they are pregnant the neural tube is already formed. But folic acid (or folate) is also important for preventing a different form of anemia.  So for a woman who is having difficulty consuming a healthy diet, folate supplementation can be helpful.

The key here is to understand what you are supplementing and why.  More is not always better. For example, too much Vitamin A can lead to problems for your baby. The goal of supplementation is to temporarily maintain the optimum nutrition for a woman during a time of nutritional stress.

If you have done any work with pregnant women, you have probably seen that how a person eats is a VERY personal matter.  Families who seek advice and information on nearly every other topic can seem to drift off into space if you start talking nutrition. So, how do you help a woman get optimum nutrition? That will depend on the woman.  But here are some questions to think about as you formulate a plan.

1. Is the woman ready to learn? Is she interested in what you have to say and trust the information you give her?  Is she open to making dietary changes and learning about ways to improve her nutrition? If not, you are likely wasting your time.

2. Do you know what problems she has with her diet? You can make assumptions, but unless you know what challenges she faces you cannot help her overcome those challenges.  Does she have access to food, meaning she can get to a place to buy food and money to purchase that food?  Does she have a way to store and prepare food, meaning she can actually refrigerate foods that require it and has the tools needed to cook?  Does she know how to cook food, meaning she understands how to use recipes and feels comfortable preparing her own meals? Does have time to eat, meaning she is able to purchase or prepare meals when she needs them rather than skipping meals? Is her biggest challenge not knowing how to plan a menu following recommended nutrition guideline?

3. Do you know what she normally eats? Recommended diet changes are more likely to be accepted if they follow her normal eating plan.  If you are working with a vegetarian who needs more protein, help her identify vegetable sources she likes.  If you are working with a woman who is lactose intolerant who needs more calcium, help her identify lactose free dairy alternatives and high calcium plant foods. How does she normally prepare her foods and what types of foods does she like?

4. Are you telling her what to do, or helping her learn? Giving her a list of foods to eat may be interesting, but probably doesn’t help the woman learn to solve her own nutrition problems.  Instead, have her do a 24 hour diet recall and work through her normal eating with her as she discovers where her diet may benefit from change.

5. What can she teach you? If you are truly partnering with a woman to help her improve her health, you should be willing and able to learn from her as well.  As you discuss nutrition, ask her questions and show that you are interested in how she as handled her own nutrition challenges.  She may be able to share a great recipe, introduce you to a great grocery or farmer’s market or show a food idea other families can benefit from.

Now that you have matched her needs to your teaching, here are a few other pointers you might find useful.

Reinforce what she does correctly, Celebrate what she is already doing right and build from there.

Set realistic goals, Think in small steps that she can achieve in a week. This lets her build gradually and be successful to encourage her to continue making changes.

Commitment to change, Make sure that she is on board with the plan.  This is most easily done if she had a major part in preparing the plan.

Have you seen the latest weight gain recommendations from the IOM?  They are the same except an increase for the highest BMI levels. Low BMI gain 28-40 pounds; Normal BMI gain 25-35 pounds; High BMI gain 15-25 pounds and Obese BMI gain 11-20 pounds.

I personally am a fan of increasing the weight gain for obese individuals.  I’ve always been frustrated that to ensure the recommended weight gain it meant an obese woman actually losing weight during pregnancy (when you adjust for the growth of the baby and the placenta). I prefer to focus on what a woman eats, and if her nutrition is appropriate than not worry so much about the number on the scale.

But my mind may have been changed recently. As we discussed prenatal nutrition, one of my instructors pointed out that it can be very difficult for an obese woman to gain “enough” weight during pregnancy (with enough meaning the recommended weight gain) because to maintain her body weight takes a significant amount of calories.  During early pregnancy, with nausea and food aversions many women (obese included) have difficultly consuming their customary amounts of food.  Without the high caloric intakes to maintain the weight, obese women often lose significant numbers of pounds early in pregnancy.  I hadn’t really thought about that before, but it does make sense. Maybe I can be a little less frustrated with the weight gain recommendations now.

So how do you know if a woman is eating an adequate number of calories during pregnancy?  You do the math.  The equation is to take her optimum prepregnancy weight in kg (about the middle number of the normal BMI for her height or use the old Metropolitan Life Charts), and multiply that number by 35 calories.  This is her pre-pregnancy calorie need.  Add 300 to the number and that is about the number of calories she needs everyday for a healthy pregnancy.

There is another method, called the Higgins Intervention Method, that Varney’s Midwifery introduced to me. Created by the Montreal Diet Dispensary, it uses charts of the desired weights by height (those Metropolitan Life Charts again) and charts of calorie requirement for weight and activity level (From the Canadian Dietary Standards for Female Adults).  This method seems to add 500 calories and 25 grams of protein per day after 20 weeks pregnancy without any increase prior to 20 weeks. For a multiple pregnancy you add the 500 calories and 25 grams protein for each fetus.

What is interesting about the Higgins Intervention Method, is that it also changes based on other characteristics of the mother.  If the mother was more than 5% under weight, she adds an additional 500 calories and 20 grams per day.  If she has nutritional stress such as close pregnancy spacing or pernicious vomiting, she adds 200 calories and 20 grams of protein for each stress inducing condition.

When it comes to pregnancy nutrition, there seem to be two types of people. Those who feel it is of the utmost importance, and those who feel it doesn’t matter. Want to know which side of that fence I am on?  Here is some information straight out of Varney’s Midwifery  to help you figure that out.

Low birth weight babies, whether they are small for gestational age or premature, have increased rates of perinatal mortality, mental retardation, cerebral palsy, learning disabilities, visual and hearing defects, neurological defects and poor infant growth and development. Factors that influence birth weight are: maternal disease, smoking, gestational age and maternal malnutrition. Maternal malnutrition is related to two factors, the prepregnancy weigh and the weight gain during pregnancy. That’s all.

That doesn’t quite tell the whole story.  We do know that two things seem to cause the baby’s growth to not be optimum; placental problems and poor nutrition.  But these two do not produce the same results.  When growth is restricted by the placenta, brain growth is protected even though the rest of the growth is hindered. When growth is restricted by inadequate nutrition, the brain is not spared.

Varney’s tells a chilling tale, does it not? It goes on to break down birth weights to explain what birth weights have the optimum health, and its higher than you think.  3500 – 4000 grams, which is between 7 lb 12 oz and 8 lb 14 oz. Many women might even consider these babies “big” wishing instead for a more petite version.

So we can accept nutrition is important, but that is about all I see most people will agree on. Why? Because  the food you eat is a very personal, culturally specific and emotionally charged issue. Diet is a difficult subject to bring up because families have many reasons for eating the way they do.  Finances, access to foods, experience with foods, culture and time limitations are all mixed in. So when they come to you as the midwife, and you tell them to eat well for pregnancy, what have you really told them?

It goes the opposite way too.  I have meet birth professionals who spend majority of their time focusing on the importance of  organic or whole foods or vegetarian or high protein diets. None of these things are necessarily wrong, but if you are working with a family that does not yet eat two servings of vegetables a day, you are missing an opportunity to help them make the first step.

So how do nutritional needs change during pregnancy?  They actually change very little from the standard nutritional needs.  Most nutrients needs are the same, or nearly the same for pregnant and non-pregnant women.  The big differences are that protein needs rise to 71 g per day on average and total calorie need increases by 300. In addition, pregnancy does increase your iron needs.

The recommended breakdown of food groups to meet these needs is as follows:   Fruits – 1.5 cups;  Vegetables – 2.5 cups;  Grains – 6 oz eq;   Meat and Beans – 5 oz eq;   Milk 3 cups.

And for those of you who read that list and feel frustrated that women will not get optimum benefits from eating like that unless they choose organic or whole food or whatever you personal preferences are in food, I share with you the wisdom of one of my favorite midwives: The research shows these benefits from the plain old stuff they sell in the grocery store.  If you can get her to eat it, she’s get these benefits.