WHO recommendation on nutrition education on energy and protein intake during pregnancy

WHO recommendation on nutrition education on energy and protein intake during pregnancy



In undernourished populations, nutrition education on increasing daily energy and protein intake is recommended for pregnant women to reduce the risk of low birthweight neonates.

(Context-specific recommendation)


Publication history

First published: November 2016

Updated: No update planned

Assessed as up-to-date: November 2016



  • Undernourishment is usually defined by a low BMI (i.e. being underweight). For adults, a 20–39% prevalence of underweight women is considered a high prevalence of underweight and 40% or higher is considered a very high prevalence (1). Mid-upper arm circumference (MUAC) may also be useful to identify protein–energy malnutrition in individual pregnant women and to determine its prevalence in this population (2). However, the optimal cut-off points may need to be determined for individual countries based on context-specific cost–benefit analyses (2).
  • Anthropometric characteristics of the general population are changing, and this needs to be taken into account by regularly reassessing the prevalence of undernutrition to ensure that the intervention remains relevant.
  • The GDG noted that a strong training package is needed for practitioners, including standardized guidance on nutrition. This guidance should be evidence-based, sustainable, reproducible, accessible and adaptable to different cultural settings.
  • Stakeholders might wish to consider alternative delivery platforms (e.g. peer counsellors, media reminders) and task shifting for delivery of this intervention.
  • Areas that are highly food insecure or those with little access to a variety of foods may wish to consider additional complementary interventions, such as distribution of balanced protein and energy supplements (see WHO recommendation on energy and protein dietary supplements during pregnancy).



Pregnancy requires a healthy diet that includes an adequate intake of energy, protein, vitamins and minerals to meet maternal and fetal needs. However, for many pregnant women, dietary intake of vegetables, meat, dairy products and fruit is often insufficient to meet these needs, particularly in low and middle-income countries (LMICs) where multiple nutritional deficiencies often co-exist. In resource poor countries in sub-Saharan Africa, south-central and south-east Asia, maternal undernutrition is highly prevalent and is recognized as a key determinant of poor perinatal outcomes (3). However, obesity and overweight is also associated with poor pregnancy outcomes and many women in a variety of settings gain excessive weight during pregnancy. While obesity has historically been a condition associated with affluence, there is some evidence to suggest a shift in the burden of overweight and obesity from advantaged to disadvantaged populations (4).



The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (5). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (6) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (7) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (8) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.


Recommendation question

For this recommendation, we aimed to answer the following question:

  • For pregnant women in undernourished populations (P), does energy and protein dietary education (I) compared with no intervention (C) improve maternal and perinatal outcomes (O)?


Evidence summary

Evidence on the effects of nutritional education was derived from a Cochrane review (9). Five trials conducted between 1975 and 2013 in Bangladesh, Greece and the USA, involving 1090 pregnant women, contributed data to this comparison. Nutritional education interventions were delivered one-to-one or in group classes and included education to improve the “quality” of diet, increase energy and protein intake, or improve knowledge of the nutritional value of different foods, including energy, protein, vitamins and iron. The Bangladesh study also involved cookery demonstrations.

Maternal outcomes

Evidence on gestational weight gain was of very low certainty. There was no other evidence available on maternal outcomes in the review for this comparison.

Fetal and neonatal outcomes

Low-certainty evidence shows that antenatal dietary education may reduce low-birth-weight neonates (300 women; RR: 0.04, 95% CI: 0.01–0.14), but may have little or no effect on small-for-gestational-age (SGA) neonates (2 trials, 449 women; RR: 0.46, 95% CI: 0.21–0.98), stillbirths (1 trial, 431 women; RR: 0.37, 95% CI: 0.07–1.90) or neonatal deaths (1 trial, 448 women; RR: 1.28, 95% CI: 0.35–4.72). Evidence on preterm birth was judged to be of very low certainty.


Resource costs are variable and mainly related to staffing and counselling time.


In many LMICs, pregnancy outcomes and ANC coverage are worse among women who are poor, least educated and residing in rural areas (10). Many low-income countries still struggle with widespread poverty and hunger, particularly among rural populations (11). Findings from a study of antenatal food supplementation and micronutrient supplements in rural Bangladesh suggest that food supplementation interventions might be associated with better ANC adherence among women with less education but not among those with more education (12). Therefore, providing antenatal food supplements could help to address inequalities by improving maternal nutritional status and increasing ANC coverage among disadvantaged women.


Qualitative evidence indicates that women in a variety of settings tend to view ANC as a source of knowledge and information and that they generally appreciate any advice (including dietary or nutritional) that may lead to a healthy baby anda positive pregnancy experience (high confidence in the evidence) (13). It also suggests that women may

be less likely to engage with health services if advice is delivered in a hurried or didactic manner (high confidence in the evidence) (13). Therefore, these types of interventions are more likely to be acceptable if the interventions are delivered in an unhurried and supportive way, which may also facilitate better engagement with ANC services. Qualitative evidence on health-care providers’ views of ANC suggests that they may be keen to offer general health-care advice and specific pregnancy-related information (low confidence in the evidence) but they sometimes feel they do not have the appropriate training and lack the resources and time to deliver the service in the informative, supportive and caring manner that women want (high confidence in the evidence) (14).


In a number of LMIC settings, providers feel that a lack of resources may limit implementation of recommended interventions (high confidence in the evidence) (14).


Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:



Implementation considerations

  • The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
  • Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.


Research implications

The GDG identified these priority questions related to this recommendation

  • What are the effects, feasibility, acceptability and equity implications of healthy eating and exercise interventions in LMICs?
  • Can an intervention package with standardized guidance on nutrition be developed that is evidence-based, sustainable, reproducible, accessible and adaptable to different cultural settings?
  • Research is needed at country level to better understand the context-specific etiology of under-nutrition. Do alternatives to energy and protein supplements, such as cash or vouchers for pregnant women, or improved local and national food production and distribution, lead to improved maternal and perinatal outcomes?


Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

WHO Programmes: Department of Nutrition for Health and Development

Maternal Health




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  2. Tang AM, Chung M, Dong K, Terrin N, Edmonds A, Assefa N et al. Determining a global midupper arm circumference cutoff to assess malnutrition in pregnant women. Washington (DC): FHI 360/Food and Nutrition Technical Assistance III Project (FANTA); 2016 (http:// www.fantaproject.org/sites/default/files/ resources/FANTA-MUAC-cutoffs-pregnantwomen-June2016.pdf, accessed 26 September 2016).
  3. Rasmussen KM, Yaktine AL, editors; Institute of Medicine and National Research Council. Weight gain during pregnancy: re-examining the guidelines. Washington (DC): The National Academies Press; 2009 (http://www.nationalacademies.org/hmd/ WHO recommendations on antenatal care for a positive pregnancy experience 126 Reports/2009/Weight-Gain-During-PregnancyReexaminingthe-Guidelines.aspx, accessed 29 September 2016).
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  7. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
  8. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).
  9. Ota E, Hori H, Mori R, Tobe-Gai R, Farrar D. Antenatal dietary education and supplementation to increase energy and protein intake. Cochrane Database Syst Rev. 2015;(6):CD000032.
  10. State of inequality: reproductive, maternal, newborn and child health. Geneva: World Health Organization; 2015 (http://www.who.int/gho/ health_equity/report_2015/en/, accessed 29 September 2016).
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Citation: WHO Reproductive Health Library. WHO recommendation on nutrition education on energy and protein intake during pregnancy. (November 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.