Healthy, safe pregnancy: CSPI's research-based guide

Take folic acid

Folic acid is so important to a developing fetus that the Centers for Disease Control and Prevention, the U.S. Preventive Services Task Force, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and other health authorities recommend that anyone who could become pregnant should be taking it. Folic acid is the synthetic form of folate (vitamin B-9), which helps make new cells. Randomized controlled trials have demonstrated that folic acid lowers the risk of neural tube birth defects, which cause spina bifida and other major defects of the brain or spine.

It’s important to take 400 to 800 micrograms (mcg) a day of folic acid if you’re of childbearing age whether or not you are planning to become pregnant, because roughly half of all pregnancies are unplanned, and neural tube birth defects occur very early in pregnancy (3 to 4 weeks after conception), before many people know that they are pregnant. For some women with a history of neural tube defects or other high-risk factors, an even higher dosage may be recommended by your doctor.

Be sure to look for supplements with “folic acid,” not “folate” or “5-MTHF.” Folic acid is a form of folate, but not all forms of folate are folic acid. “No scientific studies exist that show that supplements containing other types of folate (such as 5-MTHF) can help prevent neural tube defects,” the CDC cautions.

Don’t rely on the “% DV” (daily value) or “mcg DFE” (Dietary Folate Equivalent) of folate, because the DFE includes forms of folate other than folic acid. (The amount of “DFE” accounts for the differences between the body’s ability to absorb folic acid from supplements versus naturally occurring folate in foods.) And don’t rely on supplements that contain “100% DV” for folate. That’s less than 400 mcg folic acid.

Folic acid is added to some breads, breakfast cereals, pasta, rice, corn masa flour, and other fortified foods. In fact, birth defects have declined by 28 percent since 1998, when the Food and Drug Administration required “enriched” flour to be fortified with folic acid. However, few fortified foods supply 400 mcg per serving. Foods like fruits, vegetables, and beans also contain folate, but not enough folic acid. To play it safe, take a supplement to be sure that you’re taking an adequate amount.

Take additional prenatal supplements

If you are trying to become pregnant, experts recommend taking prenatal supplements to ensure that you get enough folic acid, choline, iron, iodine, calcium, vitamin A, B vitamins, vitamin C, vitamin D, omega-3 fats, and other nutrients that support a healthy pregnancy. The descriptions below come from the American College of Obstetricians and Gynecologists (ACOG) and explain why some key nutrients are important to a developing fetus. See ACOG’s page here for more information on each nutrient.

• Calcium: Helps your fetus form strong bones and teeth. 
• Choline: Supports the development of your fetus’s brain and spinal cord. 
• Iodine: Supports healthy brain development. 
• Iron: Helps red blood cells deliver oxygen to your fetus. 
• Vitamin A: Forms healthy skin, and supports eyesight and bone growth. 
  • (Note: Taking more than 10,000 IU (3,000 mcg) a day of Vitamin A from retinol can cause birth defects. Vitamin A from beta-carotene does not cause birth defects.) 
• B Vitamins: Supplies energy for your fetus’s development and helps build the placenta. 
• Vitamin C: Promotes healthy gums, teeth, and bones and is important for a healthy immune system. 
• Vitamin D: Builds your fetus’s bones and teeth, and helps promote healthy eyesight and skin. 
• Omega-3 fats (including DHA): Supports fetal brain development.

Your best bet is to ask your healthcare provider or pharmacist to recommend a prenatal supplement. Choosing a large, well-known brand—like One A Day or NatureMade— is also encouraged. You can also look for supplements that have independent certifications on the label  from NSF or USP. Those certifications ensure that the supplement contains the ingredients listed on the label, are free of contaminants, and are likely to break down so they can be absorbed by the body.

It’s important to note that gummy prenatal supplements typically contain no iron. If your healthcare provider recommends that you take a prenatal supplement containing iron, avoid prenatal gummies or take an additional iron supplement.

Most people don’t consume the levels of choline recommended during pregnancy (450 milligrams per day), and many prenatal supplements contain little or no choline. Ask your healthcare provider whether to take a choline supplement in addition to your prenatal supplement.

It’s equally important to talk with your healthcare provider about any supplements you should stop taking that aren’t intended for pregnancy (see Section 5 subsection: “Reconsider Taking Any Supplements (other than Prenatal Supplements)”).

Healthy eating tips for a healthy pregnancy

Consuming a healthy diet before and during pregnancy and lactation may improve pregnancy outcomes, supports the growth of your baby, maintains your health, and may keep both you and your child healthy later in life.

Focus on vegetables, fruits, low-fat or fat-free dairy, healthy proteins, and whole grains 

During your pregnancy, overall advice for healthy eating is similar to that for other life stages: eat plenty of fresh or frozen vegetables and fruits, low-fat or fat-free dairy (or nutritious plant-based alternatives), whole grains (such as oatmeal and whole-grain bread), and healthy proteins.

Healthy proteins include beans, eggs, lean poultry, low-mercury seafood rich in omega-3 fats (see examples in the next subsection: “Choose Low-Mercury Seafood”), tofu, tempeh, and lightly salted or unsalted nuts and seeds.

Eating a wide variety of whole foods will provide the calories, vitamins, and minerals that you need during your pregnancy. 

You can find additional healthy eating advice for pregnancy in Chapter 5 of the 2020-2025 Dietary Guidelines for Americans.   

Choose low-mercury seafood

If you eat seafood, it’s best to choose two or more 4-ounce servings per week of fish or shellfish that are lower in mercury and higher in omega-3 fats.

Although fish and shellfish can be a great source of omega-3 fats which are important for the developing brain of a fetus, some fish can be contaminated with mercury, a heavy metal that has been linked to birth defects. Therefore, it’s important to consume seafood wisely.

The best seafood choices include:

• Anchovies  
• Atlantic mackerel  
• Butterfish
• Freshwater trout  
• Herring
• Mussels 
• Pollock 
• Salmon 
• Sardines 
• Shad

See CSPI’s handy fish and shellfish guide for more information on seafood varieties to choose or avoid.  

To increase your intake of omega-3 fats, ask your healthcare provider if a fish oil supplement is right for you and if so, what amounts will meet your needs. Algae-based supplements can be taken as a vegetarian alternative.

Do eat enough, but there’s no need to “eat for two”

It’s important to gain enough—but not too much—weight during pregnancy. Although you may have heard that you should “eat for two” while pregnant, that’s not the most precise advice.

You will likely need no extra calories during your first trimester, approximately 340 additional calories each day in your second trimester, and 450 extra calories11 each day in your third trimester on top of your usual diet, which typically varies from 1,600 to 2,400 calories. Since your calorie requirements increase as your fetus develops, gradually increasing your calorie intake over the course of your pregnancy by consuming nutrient-dense foods and beverages can help you gain a healthy amount of weight.

These extra calories should come from nutrient dense foods such as fruits, vegetables, whole grains, and healthy proteins, rather than from foods high in added sugars, salt, and saturated fat.

Stay well hydrated, but avoid large amounts of tonic water

It’s important to stay hydrated by drinking plenty of water (unsweetened, plain, or bubbly, but not tonic water) throughout the day every day. Tonic water contains quinine, which is a bittering agent and is one of the few drugs used in food (although at lower doses than used as drugs). Quinine can cross the placenta and, in high amounts, may harm your fetus. If you choose to drink quinine-containing beverages, amounts less than one liter a day are unlikely to pose a risk. To play it safe, it is best to avoid quinine during pregnancy, and instead, reach for plain water or other sparkling water without quinine.

Although hydration needs vary from person to person, it’s recommended to get around 10 cups of fluid a day during pregnancy from all beverages, including drinking water. A dry mouth, thirst, weight loss, or urine darker than lemonade can all be signs that you’re not getting enough water.

Fat free or low-fat milk, fortified plant-based milk, unsweetened, caffeine-free teas, and decaf coffee are also healthy beverages.

Limit these for a healthy pregnancy

Reconsider caffeine

A boost from caffeine can help get you through the day but be aware that consuming caffeine during pregnancy may pose health risks to you and your pregnancy.

Caffeine is a stimulant drug that crosses the placenta. Caffeine can also interfere with sleep and contribute to nausea and lightheadedness.

Avoid excessive caffeine consumption (more than 200 milligrams a day, or two 8-ounce cups of coffee a day) because it is associated with an increased risk of miscarriage, stillbirth, and low birth weight.

Remember that caffeine can be found in many foods and beverages besides coffee! They include black or green tea, energy drinks, soft drinks, chocolate, some brands of coffee ice cream or yogurt, and over-the-counter medications like Excedrin, just to name a few. Caffeine is also found in some over-the-counter medicines used for pain relief, colds, migraine headaches and some weight loss supplements.

See CSPI’s page on caffeine for a list of products that contain caffeine. 

Pay close attention to salt and added sugar

Most Americans, pregnant or not, consume too much salt and added sugar. 

Excess sodium increases the risk of strokes and heart attacks. Yet nine out of ten adults exceed the recommended daily limit for sodium, which is 2,300 milligrams of sodium per day. It’s easy to unknowingly go over that limit—some individual restaurant meals or cans of soup come close to that limit or even exceed it.17 In fact, roughly 70 percent of the salt in our diets comes from restaurant and packaged (processed) foods, not the saltshaker.

For more information about how and why to lower salt in your diet, check out our CSPI resources here.

Roughly 65 percent of  women and 60 percent of men exceed the recommended limit for added sugars (less than 10 percent of total calories). Added sugars are empty (nutrient-poor) calories, and sugary drinks can lead to weight gain, which raises the risk of type 2 diabetes and heart disease.

If you drink sugary drinks like soda, sweetened iced teas, fruit drinks, or sport drinks, it’s best to cut back or switch to plain or bubbly water. For more of CSPI’s tips on reducing added sugars, see our guide.

Steer clear of artificial sweeteners and sugar substitutes

Consider eliminating certain low-calorie sweeteners during your pregnancy.

CSPI recommends that, as a precautionary measure, all consumers and especially pregnant and lactating people avoid aspartame, ace-K (acesulfame potassium), sucralose, and saccharin because these sweeteners may pose a small risk of cancer. And, although the research is not conclusive, it is possible that high intake of diet sodas or other beverages with these artificial sweeteners may also increase the risk of preterm birth.

The evidence on aspartame is the strongest, so we recommend taking extra caution with aspartame. Several tests in animals showed that consuming aspartame increased the risk of certain cancers. Aspartame can be found in popular products such as Diet Coke and table sugar packets such as Equal.

Erythritol, stevia leaf extract, and advantame are safer alternatives.

Check out CSPI’s Chemical Cuisine for more information on the safety of alternative sweeteners and other additives. 

Minimize ultra-processed foods

Both during your pregnancy and in general, we recommend eating more unprocessed (or minimally processed) foods (e.g., fresh and frozen fruits and vegetables, whole grains, beans, and nuts) and fewer ultra-processed foods (e.g., processed meats [see Section 5 subsection: “Cured, Smoked, and Other Processed Meats Can be Dangerous”]; chips; microwaveable meals; sugary breakfast cereals; candies; nutritional shakes or meal replacements, and fast food burgers and chicken nuggets).

Ultra-processed foods and fast food are more likely to have excessive amounts of added salt, sugar, and fat, and they can contain other possibly harmful food additives (e.g., synthetic food dyes, preservatives like butylated hydroxyanisole [BHA] or Tert-butylhydroquinone [TBHQ]) compared to unprocessed and minimally processed foods.

Another concern is that many substances used in food packaging and processing equipment are not well studied and may migrate into the food. Ultra-processed foods are more likely to have had high contact with processing equipment and packaging, and are associated with higher levels of these substances, like bisphenol-A (BPA) and phthalates, in the urine.

Some of these chemicals, like bisphenol-A (BPA) and phthalates, are thought to interfere with normal hormone function at very low levels. As a precautionary measure, choose unpackaged foods and foods with minimal packaging when possible.

That said, the benefits of consuming fruits and vegetables, whether canned, packaged, or frozen, outweigh the risks posed by substances that migrate into food from packaging.

Avoid these hazards for the healthiest pregnancy

Avoid alcohol completely

Consuming alcohol during pregnancy can seriously impact the development of the fetus and should be entirely avoided.

Federal scientific authorities are clear that no amount of alcohol has been determined to be safe during pregnancy.

Avoid cured, smoked, and other processed meats

Cured, smoked, and other types of processed meats, such as hot dogs, fermented or dry sausage, deli meats, refrigerated pâté or meat spreads, and lox may not be safe to consume during pregnancy. In general, when these and other ready-to-eat meat, poultry, and seafood products are consumed cold (not heated to 165˚F just before serving), they may cause serious illness due to contamination with Listeria, a type of bacteria that can grow at refrigeration temperatures and can survive mild heat. Listeria can be deadly to fetuses and newborns. Always heat refrigerated meat, poultry, and seafood, including leftovers, until steaming hot just before eating.

It’s best for everyone, pregnant or not, to avoid or minimize processed meats, because health authorities have concluded that they increase the risk of cancer in humans.

Do not consume seafood that is high in mercury or other contaminants

While most seafood is fine to consume during pregnancy, and some are rich in omega-3 fats that may benefit the developing fetus, certain fish and shellfish should be avoided because they contain too much mercury or other contaminants.

Avoid these very high-in-mercury fish (listed in descending order of mercury content):  

• Tilefish 
• Swordfish 
• Shark 
• King mackerel 
• Orange roughy 
• Marlin 
• Grouper  
• Fresh or frozen tuna 
• Spanish mackerel 
• Sablefish 
• Bluefish 
• Canned albacore (white) tuna 
• Freshwater bass 
• Saltwater trout 
• Sea bass 
• Halibut 

CSPI’s seafood guide has more helpful information on mercury-smart choices.

Steer clear of fish high in polychlorinated biphenyls (PCBs)—a group of industrial chemicals banned in 1979 that still persist in certain fatty fish—including striped bass, wild catfish, and bluefish (also high in mercury). PCBs are probable human carcinogens and have other harmful effects.  

As a general rule, avoid consuming fish caught recreationally. Check your state, territory, or tribal fish advisories for advice about fish caught in your jurisdiction. For more information on navigating your local fish advisory, check out this source from the Environmental Protection Agency. 

Also, avoid eating the “mustard” in blue crabs or the “tomalley” in lobsters, since PCBs and some heavy metals can become concentrated in those organs. Similarly, avoid stews that call for whole fish with internal organs intact, since contaminants can accumulate there.

Skip any unpasteurized beverages

While pregnant, avoid raw or unpasteurized beverages, such as raw milk, fresh-squeezed juice or ciders, and homemade eggnog. These products could contain dangerous bacteria, such as Listeria, E. coli, Salmonella, and Campylobacter, which could be harmful to you and your pregnancy.

Listeria infection can pass to your fetus and potentially cause serious illness or even death in newborns.

If it is unclear whether a beverage has been pasteurized, it’s best to simply avoid it.

Avoid raw or undercooked high-risk foods

Harmful pathogens, such as Listeria, E.coli, Salmonella, and Campylobacter, can also be found in various raw and undercooked foods.

While pregnant, avoid raw eggs and raw-egg-containing products, like cookie dough, tiramisu, and homemade or restaurant-prepared (unpasteurized) hollandaise sauce, ice cream, eggnog, Caesar salad dressing, mayonnaise, and aioli. (In contrast, packaged ice cream, eggnog, Caesar dressing, and mayo sold in supermarkets has typically been pasteurized.)

In addition, avoid cheeses made with unpasteurized milk (also called raw milk). When picking a cheese, be sure to check the ingredient label for “pasteurized milk.” If you’re not sure if a food was pasteurized, it is better to avoid it out of caution.

Take special care with soft cheeses, such as brie, camembert, blue-veined cheeses, feta, queso fresco, queso blanco, and queso panela. Be aware that queso fresco and similar cheeses have caused Listeria infections even when made with pasteurized milk.

Also, on the list to avoid are foods containing raw or rare meat, poultry, or seafood, such as partially cooked hamburgers, rare roast beef, sushi varieties that contain raw seafood, raw oysters or other shellfish, pâtés, ceviche, and tartare because raw or undercooked seafood or meat may contain harmful parasites, viruses, or bacteria.

It’s also best to avoid stuffed poultry, as raw stuffing (pre-stuffed or done at home) can be difficult to heat thoroughly to a safe temperature.

Finally, avoid raw sprouts, which may contain Listeria or other pathogens, and vegetable pâtés that contain raw eggs.

Reconsider taking any supplements (other than prenatal supplements)

While prenatal vitamin-and-mineral supplements during pregnancy are recommended, other supplements may not be safe to take while pregnant.

Most supplements have not been well studied for safety during pregnancy, and some may interact with treatments prescribed by your health care provider. As a key step, it’s best to bring all of the supplements you intend to take during pregnancy to your healthcare provider for a careful review. 

Stick to real foods (and don’t follow non-food cravings)

Some people can crave non-food items during pregnancy such as clay, paint chips, or laundry starch. This can be an important clue that they are not getting enough of certain nutrients.  

It’s best to resist these urges. Instead, talk to your healthcare provider to make sure you are getting the nutrients you need.  

Other pregnancy 'best practices'

Physical activity is important to your health

Regular exercise can support a healthy pregnancy.

Physical activity supports a healthy cardiovascular system, reduces the risk of gestational diabetes and excess weight gain during pregnancy, and can boost your mood during pregnancy and after giving birth.

Those who are pregnant should aim to get at least 150 minutes of moderate-intensity aerobic exercise (like brisk walking) per week when possible. Most people who already do vigorous aerobic activity like running can continue to do so throughout their pregnancy.

After your first trimester, avoid exercises that involve lying on your back, which can restrict blood flow to the uterus and fetus. According to ACOG, those who are pregnant should also avoid contact sports like soccer or basketball, activities that pose a high risk of falling, like downhill skiing, activities that pose a risk to overheating, like hot yoga, scuba diving, and skydiving.

Washing your hands is more important than ever

Wash your hands before preparing food, before meals, after handling raw meat, after touching pets, and after using the bathroom. Use soap and water and scrub well!

Handle raw food carefully

It’s always important to avoid cross-contamination by separating raw meat from other foods when storing and cooking.

Use hot, soapy water to wash anything that comes in contact with raw meat (including poultry and seafood), like utensils, plates, and cutting boards. Be sure to wash raw fruits and vegetables under running water before consumption.

You can find more of CSPI’s tips for avoiding foodborne illness here.

Cook and reheat your food adequately

Cook meat, poultry, and fish thoroughly, checking with a meat thermometer. When cooking, make sure seafood, beef, pork, lamb, and veal come to an internal temperature of 145˚F, ground meat and egg dishes to 160˚F, and stuffing, casseroles, and poultry to 165˚F. Be sure to reheat leftovers adequately, to at least 165˚F.

Make sure that the shells of clams, mussels, and oysters open during cooking. Throw out any shellfish that do not open after cooking.

If possible, avoid reheating food in plastic containers. Instead, reheat in oven-safe glass or ceramic cookware (see Section 4 subsection: “Minimize Ultra-Processed Foods”).

Don’t eat foods that have been sitting at room temperature for longer than two hours (or one hour in warm climates), including picnic and potluck dishes or your leftovers from a restaurant. If you’ve left food out for too long, don’t assume that reheating it will make it safe. Even if the bacteria are killed, some bacteria produce toxins that are heat-resistant.

Avoid overcooking or charring meat, bread, or potatoes when cooking and grilling to avoid creating carcinogens like heterocyclic amines and acrylamide. It’s also a good idea to choose leaner cuts of meat and marinate meat, poultry, and seafood prior to cooking. CSPI’s Safe Grilling Guide has more tips for safety and health.

Safely store leftover food

Be sure to refrigerate your leftovers within two hours of cooking, cover adequately to prevent pests or cross-contamination, and eat within 72 hours of storing. Whenever possible, it’s best to use glass cookware and storage ware instead of plastic products, which may contain substances that are not well studied and may migrate into food (see Section 4 subsection: “Minimize Ultra-Processed Foods”).

To avoid heavy metals like lead, do not use leaded crystal or imported or handcrafted ceramics to store food. If using plastic containers, avoid microwaving food in them, especially those with recycle codes 3 (which may contain phthalates) or 7 (which contains BPA), and throw away any scratched or damaged containers. You can find the recycle code typically on the bottom of a container and inside a triangle. It will look something like this: 

Avoid litter boxes

When possible, avoid cleaning cat litter boxes to reduce your risk of toxoplasmosis. If you must, wear gloves and thoroughly wash your hands afterward.

Wear gardening gloves

Wear gloves while gardening or handling dirt to avoid pathogens that may be present in soil. Don’t forget to wash your hands when you’re done!

Check your water quality

When possible, avoid using warm or hot water from the tap for drinking or cooking. Tap water may contain small amounts of contaminants or byproducts of substances used to disinfect water.

You can check your water quality by contacting your water provider. To find out if there is lead in your drinking water, use this guide by the US Environmental Protection Agency (EPA).

If you rely on well water, use this guidance from the US EPA to learn about, test, and care for the drinking well you rely on.

If your test results show contamination of lead, arsenic, nitrates, VOCs (volatile organic compounds), or other contaminants in your water, consider installing a water filtration system in your home. For more information, check out NSF International’s guide for water purification systems.

The key is to know the problem you are trying to solve and install the right filter for the job.

Communicate regularly with your healthcare provider

Be in regular contact with your doctor or healthcare provider to monitor your pregnancy and discuss any questions, or brush up on healthy practices during your pregnancy. All questions are good ones!

Photo: Jonathan Borba / Unsplash.com

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