Journal of Pregnancy and Child Health
Open Access

Nutrition has been well recognized as a critical part of effective prenatal care and numerous deficiencies in both macronutrients and micronutrients have been linked to negative health outcomes in this regard. From a maternal perspective, poor nutrition can lead to issues during the pregnancy and afterwards. Specifically, issues such as gestational diabetes, pre-eclampsia, eclampsia and metabolic syndrome can result from poor maternal nutrition during pregnancy and result in ongoing health problems after delivery [1]. Likewise, poor nutrition certainly leads to negative outcomes related to the fetus or infant. These negative outcomes can include preterm delivery, intrauterine growth retardation, birth defects, congenital anomalies and metabolic effects [2]. Therefore, nutrition is an incredibly important part of effective prenatal care.

To expand on this subject further, a number of important nutrients have been found to be critical during pregnancy and fetal development. For example, folic acid deficiency is linked to neural tube defects, iodine deficiency associated with cretinism and iron deficiency identified with low birth weight. Likewise, low zinc levels place women at higher risk for preterm labour [2]. More recently, research has linked excessive nutrition to maternal obesity as well as obesity and metabolic risks in infants. While overweight mothers have increased risks for coronary disease, diabetes and metabolic syndrome, their infants have been shown to have higher risk for similar conditions due to presumed nutritional programming and the alternate expression of specific genes [3]. This has escalated concerns about effective nutrition during pregnancy for both mother and child alike.

General problem statement

While concerns regarding proper nutrition during pregnancy are increasing, the capacity to address these concerns seems to have been limited to date. Both patients and providers have expressed interest and have supported nutrition as a priority during this period of time, but effective nutritional instruction is often lacking [4]. This has continued to be the case despite an increase in the number of resources available for such information [5]. Even the Internet has increased accessibility to nutritional information for expectant mothers and most mothers utilize this as a resource [6]. However, none of these resources have seemingly made a tremendous impact on nutritional behaviors during pregnancy compared to baseline activities [5]. Therefore, the general problem currently involves a need to change nutrition and lifestyle choices among pregnant women in an effort to improve healthcare outcomes in both maternal and infant populations.

Specific problem statement

Understanding a general need to improve maternal nutrition during pregnancy, specific problems involve the identification of effective interventions to change existing patterns of nutritional behaviors. Research has provided good directions in defining which nutrients and dietary behaviors are important during pregnancy. Several micronutrients have specific dosing ranges for healthy consumption during pregnancy [2]. Likewise, other guidelines have identified ideal dietary behaviours, weight control measures and macronutrient intake during pregnancy as well [7]. The need currently is to define specific interventions that will advance adherence to these guidelines among all populations to enhance maternal and infant well-being [8]. This has implications not only for providers and patients but also for global populations now and in the future.

Purpose statement

The purpose of this integrated review seeks to address the general and specific problems identified related to nutrition and pregnancy. Literature and systematic reviews have noted that a paucity of studies in the past have addressed the efficacy of various interventions in this area [9]. However, such reviews have not been conducted in recent years and a fresh look at research evidence is needed to further clarify practice changes and to guide ongoing research in the future. Therefore, the purpose of this review is to define specific characteristics of effective interventions that enhance maternal nutrition during pregnancy and to identify gaps where further study is needed.

Research questions

The research performed addressed the following research questions:

Q1: Which dietary intervention programs in pregnancy (and specific components of these programs) are effective in promoting better nutritional behaviours among mothers?

Q2: What barriers exist to implementing effective nutritional interventions in pregnancy that needs to be overcome?

Hypotheses

Through an integrative literature review, recent primary research evidence will be reviewed and analyzed to assess the effectiveness of various dietary interventions as well as the potential barriers that exist presently to their implementation. The following null and alternative hypotheses served as the foundation for the study:

H10: Current dietary interventions in pregnancy are ineffective in improving maternal nutritional behaviors.

H1A: Current dietary interventions in pregnancy are effective in improving maternal nutritional behaviors.

H20: Barriers to effective implementation of dietary intervention programs in pregnancy are not present or do not cause significant issues.

H2A: Barriers to effective implementation of dietary intervention programs in pregnancy are present and cause significant issues.

To better guide the integrative review in relation to the specific research questions, a baseline review of existing literature was performed. Research evidence that offered systematic reviews and literature reviews related to nutrition and pregnancy were assessed through research databases in an effort to define current levels of understanding. With this in mind, baseline information was collected regarding current provider and patient knowledge levels and barriers in communication, established dietary requirements in pregnancy and potential negative effects from malnutrition and information resources available and the current state of affairs of dietary interventions in pregnancy. These are summarized in the following sections.

Overview of literature-provider-patient knowledge and communication barriers

A few of the literature reviews examined existing knowledge among stakeholders as well as issues related to effective knowledge transfers. Arrish and colleagues examined nutritional knowledge among midwives and their role in educating pregnant mothers in a literature review [2]. Findings showed that most midwives had limited knowledge in this area and likewise, a significant gap existed between what the literature has established as nutritionally important and their common insights. Though not definitive in the authors’ conclusions, they attributed these deficiencies in a large part to inadequate education and training in both undergraduate and graduate settings among midwives [2].

Lucas and co-workers also examined this subject area in a systematic review that included both qualitative and quantitative studies [5]. In reviewing 25 studies between 2002 and 2014, the researchers found that providers in general provided inadequate amounts of information to pregnant women about nutritional needs and preferred dietary behaviors. This occurred despite acknowledging that this practice was important [5]. In their review, the authors also identified three barriers that needed to be overcome in the process. These included insufficient time, a lack of resources and inadequate training in nutritional knowledge [5]. Thus, it has been recognized that ideal nutritional instruction and education is lacking in this setting and that limitations and barriers may be present.

Overview of literature-nutritional needs and malnutrition effects

The existing literature is rather extensive regarding specific nutritional needs for women during pregnancy and this involves both micronutrient and macronutrient areas. From the perspective of micronutrients, Gernand and co-workers provided a comprehensive review article summarizing specific needs. Major micronutrients that deserve attention during in pregnancy include folic acid, iodine, zinc, iron, copper and selenium as well as several Vitamin A, Vitamin B6, Vitamin B12, Vitamin C, Vitamin D and Vitamin E [2]. Except for Vitamin A, Vitamin D and Vitamin E, each of these micronutrients require higher dosing in pregnancy due to fetal tissue growth or enhanced maternal needs [2].

Macronutrient requirements are more focused on avoidance of unhealthy dietary foods in addition to the inclusion of healthy ones. Hillier and Olander performed a systematic review that involved 11 studies and they identified that effective nutrition strategies involved an increase in fruit, vegetable and overall energy intake, but at the same time, they also involved reductions in fried foods, eggs, fast foods and caffeinated beverages [9]. These recommendations have been correlated with preferred dietary practices in pregnancy to reduce the risk for excessive weight gain and obesity [9]. At the same time, reasonable macronutrient diets reduce various complications in pregnancy such as preterm delivery and gestational hypertension and diabetes [10].

Expanding on this further, Marchi and colleagues identified several conditions that may result from poor macronutrient intake and obesity [1]. In addition to the conditions just cited, others also include pre eclampsia, large-for-weight babies, depression, congenital anomalies and neonatal deaths. In addition, the rates of Caesarian section and instrument delivery are more common with maternal obesity and the number of obese women breastfeeding has also been found to be reduced when compared to non-obese mothers [1]. Deficiencies in minerals and vitamins in pregnancy have also been associated with higher rates of maternal infection [1]. From the infant’s perspective, such deficiencies can lead to conditions like low birth weight, neural tube defects, cretinism and prematurity [2]. This literature nicely summarizes pre-existing knowledge regarding nutritional needs and malnutrition effects in pregnancy.

Overview of literature-nutrition information and educational resources

Based on prior literature, most pregnant women receive nutritional information from their providers. Midwives are common sources of such information, but as highlighted by Arrish and colleagues, this knowledge source is often less than ideal [4]. Likewise, other providers experience barriers to information transfer as indicated by the review by Lucas and co-workers [5]. With this in mind, evidence exists showing that many expectant mothers access the Internet as their information source for nutritional guidance. Sayakhot and Carolan- Olah, performed a systematic review of 7 studies examining Internet usage for this purpose [6]. The findings showed that pregnant women accessed the Internet at least once monthly, searched topics about fetal development and nutrition the most and occurred most commonly among nulliparous women with higher education [6].

In past reviews, the use of technology-related interventions to advance nutrition education among pregnant women has been infrequently studied. O’Brien et al. performed a systematic review and found only 5 randomized controlled trials at that time [8]. Despite technology offering reduced cost and utilization of resources, there was inadequate data to determine if this mode of information transfer was efficacious for pregnant populations [8]. As noted by Lucas et al. more effective educational resources are needed in relation to maternal nutrition information [5]. Technology-based options deserve further attention in this regard.

Background literature analysis shows that nutrition knowledge and practices among pregnant women remains less than ideal with both undernutrition and overnutrition being common issues and leading to health-related issues in both mother and fetus [2]. Likewise, barriers to effective communication exist and interventions that have been shown to be efficacious have yet to be defined [5,8]. These areas therefore continue to represent key gaps in the existing literature. From this perspective, an integrated literature review will be conducted using relevant search terms, inclusion and exclusion criteria and interpretive analyses to assess the current research evidence in this subject area in order to promote positive policy and practice changes and guide further research.

Research method and design appropriateness

In an effort to explore answers to the research questions noted previously, both quantitative and qualitative studies were considered. By objectively analyzing data and by reviewing statistical analyses, quantitative studies offered greater opportunities for more definitive changes in policy and practice related to maternal nutrition and dietary behaviors. However, the inclusions of qualitative studies in this subject area were also included as resource to guide ongoing research and identify problematic areas of concern. As a result, the research method and design selected involved a review of recent studies involving primary research that included both quantitative and qualitative research designs. Primary studies that examined interventions to enhance nutrition in pregnancy were sought as were those that suggested barriers to effective interventions.

The research design selected for the current project involved a descriptive study that provided an integrative review of the recent literature concerning nutritional interventions in pregnancy. Key areas of importance for literature selection involved studies supporting efficacy of various interventions, intervention types and features and the primary areas where improvements have been made to date. These categories have been defined as being most important based on a summary of previous literature reviews. Likewise, this approach will help identify which interventions should be adopted at the present time and where ongoing research is needed. Therefore, the design selected aligns well with the purpose of the research.

Population

The target population for this study involved all pregnant women. Since nutritional concerns vary from undernutrition to overnutrition, specific nutrients, dietary habits and lifestyles were not of primary interest in this review. Instead, nutritional instruction, education and behavior were considered most important and therefore, these subjects were explored in relation to all pregnant women regardless of age, national origin or concurrent medical illness. To a secondary extent, behaviors and activities among providers were identified as relevant since they pursued specific interventions involving nutritional instruction and education for the target population. All primary care providers, including midwives, were considered relevant to this review.

Sampling frame

The sampling frame for this research study involved all primary research studies, both quantitative and qualitative, that explored efficacy of interventions and related barriers in the target population relevant to nutritional education and lifestyle change. Systematic reviews, literature reviews, meta-analyses and meta-syntheses were not included in the sampling frame. Likewise, the sampling frame was limited to primary research studies published in 2014 or later. Studies that examined maternal outcomes, fetal outcomes or both were considered for inclusion in the sampling frame.

Data collection

The data collection involved a literature review process that searched specific keywords within common research databases for primary research studies. Primary research studies need to involve an examination of specific interventions that aimed to enhance nutritional education and/or dietary changes among pregnant women. Recent research literature was searched from various databases that included Google Scholar, PubMED, CINAHL and PsychINFO using various keywords using Boolean search strategies. Keywords included pregnancy, diet, nutrition, intervention, maternal health, fetal health, education, instruction and randomized controlled trial. Likewise, the search for data was limited to research studies published after January 1st, 2014. Title and/or abstract review was initially performed to assess for relevance to the subject matter and purpose in the integrated literature review and subsequently, article review was performed after screening to determine final inclusion or exclusion.

Inclusion criteria for the integrated literature review included studies that involved peer-reviewed, primary research. This included both qualitative and quantitative research. Subject matter had to pertain to nutrition in pregnancy and an intervention had to be employed or assessed as part of the research focus. Exclusion criteria omitted studies that were published in a non-English language, were published before January 1st, 2014 and/or examined child outcomes later in life as the primary research effort. Once studies selected for the literature review were identified, each study was reviewed in detail and key data were extracted for integrative analysis. These data measures included intervention types, intervention characteristics, sample populations, assessed outcomes and resultant statistical analyses of results.

Data analysis

The data stated above was collected and reviewed for each of the included studies. Subsequently, a summative analysis was conducted with descriptions of the findings to allow integration and synthesis of the information. This provided the basis for the results of the literature review in an effort to address stated research questions and hypotheses while also helping highlight areas where additional research is needed in this subject area. This information will then be used to form recommendations for practice and policy changes as well as for future research efforts.

Based on the existing reviews in the literature, specific interventions to enhance maternal nutrition and dietary behaviors during pregnancy have yet to be well established. Likewise, the barriers that interfere with effective interventions have not been fully described. Therefore, an integrated literature review of recent primary research involving this subject area was performed to better guide clinical practice and to direct future research. The literature review search and design identified a total of 9 primary research studies that met inclusion and exclusion criteria. Each of these was analyzed and summarized identifying key findings and terms within each study. Based on these efforts, the results could be categorized according to three specific areas. These areas included nutritional interventions that targeted behavioral and lifestyle changes in pregnant women, interventions that assessed maternal health outcomes and interventions that assessed fetal or neonatal outcomes. Some of the research studies could be included in more than one area of assessment. These results are summarized as follows.

Interventions focused on behavioural and lifestyle changes

Of the studies included in the literature review, four assessed lifestyle choices in diet and nutrition among pregnant women. As a foundational assessment, Whitaker and colleagues conducted a qualitative study involving 30 pregnant mothers and 11 care providers in an effort to evaluate attitudes and practices related to nutritional education and choices. Statistically, both providers and pregnant women interviewed valued nutritional information and advice, which ranged between 91% and 100% [11]. However, despite this, actual nutritional education and advice fell well short of accepted practice guidelines [11]. Several barriers were again noted in relation to time, resources, training, cultural differences and levels of interest. However, the takeaway from the study was that motivations for lifestyle changes are present for both providers and patients in relation to nutritional education and instruction [11]. In another survey research study, over 12,000 pregnant women were evaluated at baseline and a year later throughout 7 major districts in India [12]. These women underwent one of two tiers of intervention, with one being more intense, that involved community level meetings that provided nutritional education and instruction during pregnancy [12]. Labelled the Sure Start program, healthy behavior changes related to diet and enhanced healthcare seeking behaviors responded well to the interventions when comparing baseline to post-intervention survey data. The benefits were also more pronounced with the higher intensity intervention [12]. These findings support positive effects of the intervention on lifestyle and behavioral change.

The other two studies were randomized controlled trials that utilized an intervention to assess behavioral or lifestyle changes in nutritional and dietary patterns. Hillesund and co-workers assessed 508 nulliparous women as part of the Norwegian Fit for Dietary Study who either received two counseling sessions by providers or received standard care [13]. After the study completion, the intervention group notably had a higher intake of fresh fruits and vegetables, reduced intake of sugars and increased practices related to label reading, satiety monitoring and limited portion size [13]. In another prospective, randomized controlled trial, Bosaeus and colleagues introduced dietary counselling as well as part of a longitudinal dietary intervention [14]. When compared to controls, pregnant women in the intervention group had a notable increase in fish and lean meat consumption [14]. Both of these studies favor positive effects for counseling on lifestyle and behavior changes that favor enhanced nutrition among pregnant women.

Interventions focused on maternal outcomes

In assessing the primary research studies selected regarding maternal outcomes, five were identified and all examined maternal weight in some form or fashion in relation to the intervention. In the aforementioned randomized controlled trial by Bosaeus and colleagues, the focus was on weight gain since an undernourished population was the primary concern [14]. In this study, the dietary counseling intervention increased fat-free meat and protein intake and this was associated with positive weight gain in pregnant mothers in the first trimester [14]. However, in a study by Rauh and co-workers, a randomized controlled trial involving 250 pregnant women failed to show any significant change in postpartum weight after a nutritional counselling intervention [15]. Though trends in a lower postpartum weight was noted at one year in the intervention group when compared to controls receiving standard care, the differences failed to reached statistical relevance [15].

Ronnberg and co-workers also examined the effect of an intervention on maternal weight [16]. The intervention consisted of education about ideal weight goals, use of weight graphs and monitors and exercise and nutritional guidance. While 41% of the pregnant women in the intervention group exceeded ideal weight guidelines and 50% of the control group did, the results failed to reach statistical significance. Again, the authors noted that the intervention was practical and low cost, but the efficacy of the intervention failed to show positive benefits [16].

One notable study involved the use of a smartphone application to provide and support special dietary and exercise advice to pregnant women [17]. A total of 565 overweight or obese pregnant women were enrolled in a randomized controlled trial with half receiving usual care [17]. The incidence of gestational diabetes was then compared between the two groups in addition to weight changes. The findings failed to show any benefit of the mobile phone technology intervention despite its inherent advantages in cost and resource utilization. In fact, the intervention group had a slightly higher incidence of gestational diabetes [17].

The final study examining maternal outcomes related to a nutritional intervention examined the effect 7 sessions of one-on-one counseling had on pregnant women [18]. McGiveron and colleagues provided the intervention to 89 women who had a BMI greater than 35 while a similar number in the control group received usual care. Several maternal outcomes were recorded over the course of their pregnancy. Specifically, the intervention group had greater weight gain, reduced risk of gestational hypertension, reduced pregnancy complications and reduced postpartum hemorrhage. No differences in labor complications or gestational diabetes were noted [18].

Interventions focused on fetal outcomes

Of the studies included, few evaluated fetal outcomes as part of maternal nutritional interventions. In the previously mentioned Sure Start program by Acharya and co-workers, the community level meetings that educated about nutritional strategies showed positive behavioral change, but the fetal outcomes failed to show any different in neonatal mortality [12]. Likewise, in the study by Rauh and colleagues examining the effect of nutritional counseling before and after pregnancy, infant weight in the intervention group was not significantly different when compared to infants from the control group [15]. These studies both fail to support benefits of nutritional interventions on fetal outcomes, but at the same time, both are very limited in scope and outcome measures evaluated. The only other research study related to fetal outcomes examined the effect a personalized mobile health technology application had on pregnant women’s behaviours [19]. Among 1,053 pregnant women, the Smarter Pregnancy application provided nutritional and lifestyle coaching over a 26-weeks period. Though exact fetal outcomes were not measured, a total risk score was calculated based on changes in nutritional and lifestyle patterns [19]. The results of the risk score indicated that a significant benefit was achieved in increasing fetal and neonatal health opportunities [19]. Though the results are far from definitive and other factors and variables are likely involved, the intervention may have offered some benefits on fetal outcomes related to nutritional changes (Table 1).

Table 1: Integrated literature review summary table.

In focusing on the most highly relevant studies reviewed in this study, a few deserve mention. The qualitative study performed by Whitaker and colleagues, is quite helpful in terms of identifying key barriers that may interfere with effective dietary and nutritional interventions among pregnant populations [11]. Time constraints, inadequate training and education, lack of resources and cultural variations need to be further addressed in terms of defining specifics and in relation to targeted strategies to overcome these barriers [11]. Having identified major obstacles in this qualitative study, specific interventions can be devised and evaluated to determine if they are effective in advancing nutrition during pregnancy.

Secondly, the studies by Hillesund et al. [13] and by McGivern et al. [18] offer additional insights that appear relevant. Both studies involved reasonably sized samples and both demonstrated statistically significant findings. The insights provided by Hillesund et al. showed how multiple outcomes need to be measured to assess intervention efficiency [13]. This comprehensive approach to examining dietary behaviors as well as objective nutritional outcomes can provide better guidance in developing effective interventions [13]. The study by McGivern and colleagues was beneficial in demonstrating how intensive education and counseling can have a more profound impact on dietary and nutritional outcomes in pregnancy [18]. In examining a high-risk population, high-intensity services showed benefits. This offers important information about how interventions may need to be personalized and structured based on risks [18]. These studies among the ones sampled offer the best guidance to date in this subject area.

Based on the integrated literature review performed, the ability to answer the two research questions was partially satisfied. At this point in time, the effectiveness of various dietary and nutritional interventions cannot be definitively identified based on the limitations of the literature. While counseling, education and instruction are supported as low-cost measures that yield positive outcomes in some studies, much work needs to be done before clear clinical guidelines can be given in this area. In terms of barriers to effective interventions, the literature does identify several areas. These include limitations in time and other resources, inadequate training and provider education and cultural variations in practice. These should be used to guide better intervention methods.

Given these findings, the first null hypothesis cannot be rejected or accepted at this time. Efficacy or inefficacy of various interventions has yet to be defined adequately. The null hypothesis for the second hypothesis can be rejected however. Barriers do currently exist in effectively administering dietary and nutritional guidance to pregnant women and these do cause significant problems in meeting counseling and educational standards.

In summarizing the literature review findings related to pregnancy and nutritional interventions, several limitations are noteworthy. First and foremost, a small number of primary research studies have been conducted that examine the efficacy of nutritional and dietary interventions in this population. Though some exist, each adopts different types of interventions, durations and frequencies as well as different outcome measurements. Thus, the actual number of research studies that can be compared based on similarities is quite small because of issues of variance. This markedly limits the ability to apply existing current research evidence to policy and practice. Secondly, in addition to variance in methods and paucity of studies, the outcomes are likewise varied with some showing statistically significant benefits and other failing to do so. Inconsistency in the results provided also limits the ability to apply the results of policies and practices and raises concerns about the rigor of the existing research available. The differences in the results among the studies cited can be attributed to several possible factors. Many of the studies have smaller sample sizes, but not all fall into this category. However, most all of the studies examined fail to account for potential confounding variables and thus validity of the results of each remains questionable in many cases. Finally, limitations related to study design, measurements and statistical analyses are evident in the literature reviewed concerning this subject. Given the heterogeneity of methodologies, inability to effectively control confounding variables and small sample sizes in many studies, it is not surprising different results have been cited among similar interventions.

Lastly, limitations related to specific outcome metrics are also present. As noted, some studies focus on outcomes related to maternal or infant weight gain while others focus on weight loss. Others examine complications of mother and fetus and still others simply assess dietary and nutritional changes in behavior. All of these are important, but reliable instruments that have been validated for these measurements are limited and not routinely used in these studies. Likewise, interventions fail to detail the precise focus in the interventions related to nutrition as it pertains to outcomes measured. Some focus on weight management, caloric intake and macronutrients while others include micronutrient instructions as well. Greater consistency in describing the type of nutritional guidance employed in addition to reliable and validated metrics are needed. These summarize the major limitations noted in the research presently as it pertains to nutrition and pregnancy.

Application of findings

Despite the limitations noted, the findings in the literature can be applied to current policies and practices as well as to research efforts. Several clinical im0plications exist from this review. First, several studies noted that some nutritional interventions are low in cost and resource utilization and therefore, risks associated with such interventions are low as well. Therefore, one clinical implication from this review identifies that it is reasonable to pursue these types of interventions despite the mixed efficacy results in the current literature. Research evidence is present to guide specific educational and instructional efforts and these should be utilized in various interventions whether they involve counseling, mobile health technologies, provider instruction or other modalities until clear efficacy or non-efficacy is established.

Secondly, the majority of the literature reviewed shows that educational and instructional interventions do affect behavioral change and lifestyle choices in favorable ways among pregnant women populations. The clinical implication in this regard is that education, instruction and guidance can have positive effects on dietary behaviors and nutrition in pregnancy. The focus should therefore be on how these efforts can be best constructed to achieve the desired outcomes. Presumably, links between behavior and lifestyle and health outcomes exist and therefore, the literature evidence supports continued trials involving education and instructional interventions based on this evidence as well.

Most importantly, the evidence highlights a need for more extensive and rigorous research in this subject area. Unlike pharmaceutical interventions and surgeries involving instruments, financial backing and profit incentives may not exist to pursue an abundance of research in this area. Regardless, in an effort to achieve quality care, positive maternal and fetal health outcomes and reduce healthcare costs, investments in research related to pregnancy nutrition is needed. This will require developing reliable and valid measurement instruments, standards for assessing efficacy of nutritional interventions and greater consistency among research designs in order to determine true efficacy of these efforts. With these applications, the following recommendations can be made.

Recommendation 1: Education and instruction regarding nutrition in pregnancy should be instituted early before and during pregnancy with a broad focus on preferred macronutrient intake, micronutrient intake and ideal weight goals since these efforts are linked to positive changes in behavior and lifestyle.

Recommendation 2: Low-cost interventions that provide nutrition and instruction in pregnancy that use minimal resources seem reasonable and may provide positive impacts in maternal and fetal health outcomes. This includes provider communications, counselling sessions and technology-based applications as potential resources for such interventions.

Recommendation 3: Dedicated research is needed to better define efficacy of nutritional interventions in pregnancy, ideal duration, intensity and frequency of interventions and the array of maternal and fetal outcomes favorably affected by these interventions. These efforts will require the development of reliable and valid measurement instruments, standards for intervention implementation and cost benefit analyses of interventions.

In summary, nutrition is an important area of concern during pregnancy die to its impact on both the mother and the fetus. Prior research has identified various macronutrients, micronutrients and dietary practices that are favored to produce positive health outcomes reduce pregnancy-related complications and promote well-being of mother and child. Despite this, a paucity of research has researched the efficacy of interventions designed to enhance nutrition in this area among expectant mothers. As a result, an integrated literature review was conducted to better assess efficacy of various interventions in pregnancy related to nutritional education and instruction.

In this review, the number of research studies in recent years continues to be limited. In addition, notable variance exists among the studies available in terms of research design, intervention types, outcome measures and study results. Based on this, many limitations exist, but it should be noted that educational and instructional interventions, including technology-based ones, are low in cost and resource utilization and the vast majority do show enhanced maternal behaviors and lifestyle when employed. Other outcome measurement results are more varied. Given these findings, recommendations for continued use of low cost educational and instructional efforts should be employed in routine obstetrical practice while dedicated research should be pursued to better define optimal interventions based on efficacy and cost benefit analysis.