Vitamin D Supplementation During Pregnancy

This assignment involves a critical review of literature regarding vitamin D supplementation during pregnancy and its impact on both maternal and infant health. Students are expected to analyze various studies, identify trends and potential benefits or risks associated with supplementation, and synthesize the findings into a comprehensive report.

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Systematic review using CASP tool
Name of the Student
Name of the University
Author Note

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1. Did the review address a clearly focused question?
Yes. The researcher clearly stated in the objectives that the aim of the systematic review was
to examine and determine whether Vitamin D oral supplements alone or in combination with
other vitamins or calcium and minerals improve neonatal and maternal outcomes when
administered to women during their pregnancy (De-Regil et al., 2016). Previous studies provided
evidence for occurrence of adverse effects among pregnant women who were deficient in
Vitamin D (Burris et al., 2012). The use of Vitamin D as a nutritional supplement has been
widely accepted. Thus, the systematic review addressed a focused question in investigating the
effects of vitamin D on pregnant and infant outcomes.
2. Did the authors look for the right type of papers?
Yes. The systematic review contacted the Trails Search Co-ordinator and searched for papers
from the Cochrane Pregnancy and Childbirth Group’s Trials Register. The register contained
trial records which were identified from weekly searches of Embase and MEDLINE (Ovid),
monthly searches of CINAHL and CENTRAL (Cochrane Central Register of Controlled Trials)
and proceedings from 30 journals that were hand searched (McGowan et al., 2016). All relevant
research studies that illustrated the effects of Vitamin D supplementation on gestational and
neonatal health were included in the review. Most of the studies were randomized controlled
trials.
3. Do you think all the important, relevant studies were included?
Yes. The study intended to include all quasi-randomised and randomized trials at cluster or
individual levels. However, only randomized controlled trials were available. The review did not

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include any observational designs such as case-control studies or cohort. Nor did it focus on
cross-over trials for carrying out this meta-analysis. Any discussion that contained relevant
information on interventions that focused on Vitamin D during pregnancy in women, irrespective
of the gestation time, chronological age, fetus number or number of births were included.
4. Did the review’s authors do enough to assess the quality of the included studies?
Yes. All the references that were included in the meta-analysis after rigorously searching the
electronic database were independently assessed by two authors of the research. Duplicate
analysis was conducted for all the selected papers. Disagreements were resolved through
discussion between the two authors. At times, consultation of a third author was asked for, as
well to resolve differences that arose while including the papers. The authors of certain studies
that had been published only in the form of abstracts were contacted to procure more information
on the design and results of the study. Similar procedure was followed for those reports that had
less information on the methodology. Thus, all potentially eligible studies were screened and
included.
5. If the results of the review have been combined, was it reasonable to do so?
The results and data analysis of most of the studies were combined based on the primary and
secondary outcomes they reported. The data analysis of the studies was grouped according to the
outcomes on which they showed the effect of vitamin D supplementation. The results were
combined into the groups that showed the effect of vitamin D pre-eclampsia on women,
gestational diabetes, gestational hypertension, preterm birth, infant underweight, neonatal death
and many other parameters (Asemi et al., 2012). It was completely reasonable to combine the

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statistical results from the studies that were selected to give a broader understanding of the
efficacy of Vitamin D intervention among pregnant women and infants.
6. What are the overall results of the review?
This review evaluated the effects of vitamin D supplementation either alone or in
combination with other vitamins, calcium and minerals during pregnancy. It included 15 small
trials that involved 2833 women. 9 of those trials compared effect of vitamin D intervention
alone versus placebo or no treatment and 6 trials compared its effects in combination with
calcium in comparison with no intervention. The effects of vitamin D and calcium were not
compared with calcium or other micronutrients among the target population in comparison with
the group that received no intervention or a placebo (Asemi et al., 2012) (Brooke et al., 1980).
Women, who received daily supplements of oral vitamin D during their pregnancy, reported
significantly greater concentration of 25-hydroxyvitamin D at the end of their gestation period.
However, their response to Vitamin D supplementation was heterogeneous. No statistically
significant differences were observed for the risk of pre-eclampsia. However, two studies
reported a low risk of pre-aclampsia mong women who were on Vitamin D intervention.
Reduction in pre-eclampsia risks was statistically significant among women who received
vitamin D supplementation along with calcium (Marya, Rathee & Manrow, 1987).
Moreover, the rates of preterm births and low birth weights showed a reduction in 3 trials and
4 trials respectively where women were on Vitamin D supplementation. In addition, the
intervention demonstrated a longer birth length (4 trials) and greater head circumference among
infants who were born to women, subjected to the intervention during their pregnancy (Marya,
Rathee & Manrow, 1987) (Sablok et al., 2015). Birth weight differences were not seen between

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placebo and no intervention group with respect to supplemented groups. However, vitamin D
supplementation in combination with calcium increased the risk of preterm birth significantly in
3 trials (Diogenes et al., 2013) (TAHERIAN, Taherian & Shirvani, 2002) (Asemi et al., 2012).
Adverse effects were reported by only few trials. 1 trial demonstrated the incidence of nephritic
syndrome in a woman who was not under intervention.
7. How precise are the results?
Effects of oral Vitamin D supplementation alone when compared to no intervention or
placebo showed borderline statistical significance with respect to pre-eclampsia (average risk
ratio (RR) 0.52; 8.9% versus 15.5%; 95% confidence interval (CI) 0.25-1.05), no clear difference
in incidence of gestational diabetes (RR 0.43; 95% CI 0.05-3.45) and highly heterogeneous
response to maternal 25-hydroxyvitamin D concentrations (I² = 99%, Tau² = 554.9 and Chi² test
for heterogeneity P < 0.00001) (Sablok et al., 2015) (Grant, 2010). It ranged from 16.3 nmol/l
(95% CI 13.6-19.0) to 152 nmol/l of 25- hydroxyvitamin D (95% CI 127-177) (Mallet 1986)
(Brooke 1980). No statistically significant risks were found associated with the intervention and
risk of nephritic syndrome among pregnant women (RR 0.17; 95% CI 0.01 to 4.06). A lower risk
of preterm births (average RR 0.36; 3.3% versus 9.9%; 95% CI 0.14-0.93) and less frequent birth
weight below 2500gm was recorded from the analysis (average RR 0.40; 9.2% versus 19.6%;
95% CI 0.24-0.67). Neonatal death did not show any clear difference (RR 0.27; 95% CI 0.04 to
1.67).
Supplementation of Vitamin D along with other minerals and calcium showed less
occurrence of pre-eclampsia (5% versus 9%; average RR 0.51; 95% CI 0.32 to 0.80) (Marya,
Rathee & Manrow, 1987). No clear evidence was found for the effects of the intervention on

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gestational diabetes (RR 0.33; 95%CI 0.01 to 7.84), 25- hydroxyvitamin D concentrations and
low birth weight. Preterm births were showed more likelihood to occur before 37 weeks among
women who received the intervention (RR 1.57; 95% CI 1.02 to 2.43; low quality) (Asemi et al.,
2012) (TAHERIAN, Taherian & Shirvani, 2002). No statistically significant differences were
observed in gestational hypertension risks (RR 0.26; 95% CI 0.06 to 1.12). Therefore, it can be
stated that the results were quite precise.
8. Can the results be applied to the local population?
Can’t tell. The effects of Vitamin D supplementation, alone or in combination with calcium
or other minerals have shown improvements in increase length, pre-eclampsia and circumference
of the head at birth. However, before the interventions can be applied to all populations as a part
of routine care procedure to improve infant and maternal health outcomes, there is a need to
confirm the effects by a detailed analysis of many more randomized trials (Pludowski et al.,
2013). Definite conclusions on the safety and usefulness of the intervention in all population
cannot be drawn from the results.
9. Were all important outcomes considered?
No. The effects of an increase in serum 25-hydroxyvitamin D concentration on improved
infant and maternal outcomes in different populations that have different degrees of skin
pigmentation, body mass index and settings were not measured (Pludowski et al., 2013).
Furthermore, the effects of vitamin D supplementation among women who were diagnosed with
gestational diabetes or greater risk of pre-eclampsia were not assessed.

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10. Are the benefits worth the harms and costs?
Overdose of vitamin D supplementation can lead to several harmful effects such as
hypercalciuria, hypercalcemia, delayed ossification, growth restriction and craniofacial
hypoplasia (Vanstone et al., 2012) (Schroth et al., 2014). Thus, adequate information on effective
and safe usage of the supplement and the probable toxic effects should be considered before
applying the intervention.
Summary discussion
From the critically analyzed study, I developed the idea that maintaining maternal and
infant health safety should be my utmost priority. I need to develop competence and clinical
skills to create a sense of trust among pregnant women under my care. I need to make them
realize that they are safe in my hands and I will adopt all possible methods to ensure safety of
their child (Noseworthy et al., 2013). I will develop knowledge on the prevalence of Vitamin D
insufficiency among women and the adverse effects it can create on maternal and infant health
outcomes. I will try to develop my communication skills and gain knowledge from the patient on
their Vitamin D consumption rates. I will make them aware of the necessity of the supplement
for proper growth of the fetus. I will seek help of experienced midwives to learn the effective
dosage and timing of vitamin D administration among pregnant women who have been admitted.
A knowledgeable and competent midwife will help me identify the different approaches that I
need to develop while dealing with women who show deficiency of Vitamin D in their diet.
Showing empathy towards them would enhance in building a rapport with the women and their
families (Doust, 2016). That would provide them support if any adverse incidents of stillborn
child occur (Ayers, 2014). Thus, from the above reflections I conclude that I will display clinical
excellence while caring for pregnant women and would administer Vitamin D supplements by

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considering the effectiveness of the drug dosage and timing to prevent occurrence of any
untoward incident.

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References
Asemi, Z., Tabassi, Z., Heidarzadeh, Z., Khorammian, H., Sabihi, S. S., & Samimi, M. (2012).
Effect of calcium-vitamin D supplementation on metabolic profiles in pregnant women at
risk for pre-eclampsia: a randomized placebo-controlled trial. Pakistan journal of
biological sciences: PJBS, 15(7), 316-324.
Ayers, S. (2014). Fear of childbirth, postnatal post-traumatic stress disorder and midwifery
care. Midwifery, 30(2), 145-148.
Brooke, O. G., Brown, I. R., Bone, C. D., Carter, N. D., Cleeve, H. J., Maxwell, J. D., ... &
Winder, S. M. (1980). Vitamin D supplements in pregnant Asian women: effects on
calcium status and fetal growth. Br Med J, 280(6216), 751-754.
Burris, H. H., Rifas-Shiman, S. L., Kleinman, K., Litonjua, A. A., Huh, S. Y., Rich-Edwards, J.
W., ... & Gillman, M. W. (2012). Vitamin D deficiency in pregnancy and gestational
diabetes mellitus. American journal of obstetrics and gynecology, 207(3), 182-e1.
De-Regil, L. M., Palacios, C., Lombardo, L. K., & Peña-Rosas, J. P. (2016). Vitamin D
supplementation for women during pregnancy. Sao Paulo Medical Journal, 134(3), 274-
275.
Diogenes, M. E. L., Bezerra, F. F., Rezende, E. P., Taveira, M. F., Pinhal, I., & Donangelo, C.
M. (2013). Effect of calcium plus vitamin D supplementation during pregnancy in
Brazilian adolescent mothers: a randomized, placebo-controlled trial. The American
journal of clinical nutrition, 98(1), 82-91.

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Doust, J. (2016). Young women midwifery care: A community engagement. Australian
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supplementation in pregnancy: a controlled trial of two methods. Obstetrics &
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Marya, R. K., Rathee, S., & Manrow, M. (1987). Effect of calcium and vitamin D
supplementation on toxaemia of pregnancy. Gynecologic and obstetric
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McGowan, J., Sampson, M., Salzwedel, D. M., Cogo, E., Foerster, V., & Lefebvre, C. (2016).
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Płudowski, P., Karczmarewicz, E., Bayer, M., Carter, G., Chlebna-Sokół, D., Czech-Kowalska,
J., ... & Głuszko, P. (2013). Practical guidelines for the supplementation of vitamin D and
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Hypercalcemia in children receiving pharmacologic doses of vitamin
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