29 August 2021
WHO recommendation on high-protein supplements during pregnancy
In undernourished populations, high-protein supplementation is not recommended for pregnant women to improve maternal and perinatal outcomes.
First published: November 2016
Updated: No update planned
Assessed as up-to-date: November 2016
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 (1). 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 (2).
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 (3). 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) (4) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (5) 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) (6) 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.
For this recommendation, we aimed to answer the following question:
Evidence on the effects of balanced energy and protein supplements compared with no supplementation or placebo was derived from a Cochrane review (7). The review included one trial of high-protein supplementation compared with a micronutrient supplement conducted in the 1970s, involving 1051 low-income, black women in the USA.
None of the outcomes prioritized for this guideline were reported for this comparison in the review.
Fetal and neonatal outcomes
High-certainty evidence shows that high-protein supplementation increases SGA neonates (1 trial, 505 neonates; RR: 1.58, 95% CI: 1.03–2.41). Moderate-certainty evidence indicates that high-protein supplementation probably has little or no effect on preterm birth (1 study, 505 women; RR: 1.14, 95% CI: 0.83–1.56). Low-certainty evidence suggests that high-protein supplementation may have little or no effect on stillbirths (1 trial, 529 babies; RR: 0.81, 95% CI: 0.31–2.15; certainty of evidence downgraded due to imprecision) and neonatal deaths (1 trial, 529 neonates; RR: 2.78, 95% CI: 0.75–10.36).
In the review, mean birth weight (in grams) was reported and the findings favoured the balanced energy and protein supplementation group (11 trials, 5385 neonates; mean difference [MD]: 40.96, 95% CI: 4.66–77.26). This evidence was graded as moderate-quality evidence in the review (9).
The cost of high-protein supplements is relatively high. There may also be cost implications with respect to transport, storage and training.
In many LMICs, pregnancy outcomes and ANC coverage are worse among women who are poor, least educated and residing in rural areas (8). Many low-income countries still struggle with widespread poverty and hunger, particularly among rural populations (9). 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 and a positive pregnancy experience (high confidence in the evidence) (10). 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) (10). 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) (11).
Providing high-protein supplements may be associated with logistical issues, as supplements are bulky and will require adequate transport and storage facilities to ensure continual supplies. Qualitative evidence from LMIC settings indicates that providers feel that a lack of resources may limit implementation of recommended interventions (high confidence in the evidence) (11).
Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:
The GDG identified these priority questions related to this recommendation
WHO recommendations on antenatal care for a positive pregnancy experience
Citation: WHO Reproductive Health Library. WHO recommendation on high-protein supplements during pregnancy (November 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.
Citation: Whitworth M, Quenby S, Cockerill RO, Dowswell T. Specialised antenatal clinics for women with a pregnancy at high riskof preterm birth (excluding multiple pregnancy) to improve maternal and infant outcomes. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD006760. DOI: 10.1002/14651858.CD006760.pub2.Read Article
Citation: Catling CJ, Medley N, Foureur M, Ryan C, Leap N, Teate A, Homer CSE. Group versus conventional antenatal care for women. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD007622. DOI: 10.1002/14651858.CD007622.pub3.Read Article