We Screen For Pregnancy Complications, But Do We Prepare Women For Birth?
Last week, I asked my midwife to add B vitamin tests, zinc, copper and homocysteine to my antenatal blood request. She did. A doctor later declined the additional tests, explaining that she would usually approve them where there was a history such as gastric surgery or significant digestive disease.
I don't blame the doctor. I actually didn't even expect that she would approve everything I asked for, because I know she's working within a system that reserves extensive micronutrient investigation for established risks. But I came away with a question: what does that system count as worth knowing about a pregnant woman's body?
Luckily for me, I can arrange the tests privately and interpret the results myself. Many women cannot. And having repeatedly encountered nutrient insufficiencies in my clinical practice, I wonder whether our definition of a "normal" pregnancy assessment is too narrow. Clinical experience raises that question; it cannot tell me how common such insufficiencies are among pregnant Australians or whether testing them routinely improves birth outcomes. But, if they're even half as common as they are amongst my client case load, then they're being missed in a huge number of women. And this can have consequences for a woman during pregnancy, childbirth, and beyond - as well as for her child.
The tests I actually wanted, and why
To be specific: I requested B1 (thiamine), B6 (pyridoxine), B9 (folate) and B12 (cobalamin). I also asked for homocysteine, which matters for a different reason than the B vitamins themselves.
Pregnancy demands methylation like few other states. Methylation is the process of adding a one-carbon unit (a methyl group) to molecules like DNA, proteins, and neurotransmitters. Your body needs this for countless substrates to function. During pregnancy, methylation is required for fetal cell division, epigenetic programming, immune tolerance, and preparing your own body for labour and recovery. B6, B9 and B12 all feed directly into this process. B9 (folate) generates the methyl donor. B12 transfers it. B6 helps regulate homocysteine, a byproduct that you want to keep low.
The homocysteine test serves a similar purpose, though indirectly. Serum B2 (riboflavin) is notoriously unreliable as a marker of status, but homocysteine responds to B2 deficiency because B2 is required to recycle homocysteine back to methionine. High homocysteine can flag B2 insufficiency even when standard B2 testing is inconclusive.
I'm homozygous for the MTHFR C677T variant, which means I run through both folate and B2 more quickly than average. For me, monitoring these nutrients isn't optional. It's essential background for understanding whether my body is keeping up.
This is granular testing. It reflects a specific metabolic concern, not a blanket "let's check everything" approach.
What standard care covers, and its logic
The system that declined my request operates from guidelines that don't go far enough. But I don't blame the individual doctor. She's working within a framework that defines adequacy differently than I do. Antenatal care rightly prioritises detecting anaemia, gestational diabetes, hypertensive disorders, infections and concerns about fetal growth. Screening criteria are built around whether a test reliably identifies a problem and whether acting on its result helps. A nutrient's biochemical role alone isn't enough reason to test everyone, by that logic.
But that logic itself is the problem. It optimises for detecting established risk, not for supporting maternal capacity. It's adequate, not optimal. And like most things in the health system, it settles for adequacy when we should be asking what actually produces the best outcomes for both a mother and her baby.
Current Australian guidelines recommend screening for folate and iodine in the first trimester, with particular attention to iron, calcium and zinc throughout pregnancy, especially when risk factors are present. The logic matters. Screening criteria have to consider whether a test reliably identifies a problem and whether acting on its result actually helps. A nutrient's biochemical role alone isn't enough reason to test everyone.
And yet...
Pregnancy isn't simply the absence of a diagnosable complication. It requires expanding blood volume by up to 50%, building a placenta, tolerating immune changes, adapting glucose metabolism, and preparing uterine and pelvic tissues for labour. Recent research suggests even more may be happening at the metabolic level. The Australian guidelines recognise extended micronutrient assessment after bariatric surgery because we know that history creates genuine risk.
The question I keep coming back to is whether more individualised nutritional assessment might also be worth considering for women without that surgical history, particularly when symptoms, dietary patterns, or previous results raise a concern. Both my gut and my clinical experience say yes.
One UK study found B12 insufficiency in 42% of pregnant women in early pregnancy. Australian-specific prevalence data remains limited, but if that figure translates at all to Australian populations, we're looking at a pattern worth understanding. I don’t have pregnancy data for all of the other B vitamins, but the Australian Bureau of Statistics has found that up to 20% of Australians don’t meet the recommended daily intake for B2, let alone the increased needs in pregnancy. This also doesn’t account for absorption issues, which can reduce what’s actually taken in and used by the body. We don’t know what we’re really dealing with here, but I’m willing to bet these deficiencies are far more widespread, and especially in pregnancy, than what’s currently reported.
Why the stakes matter
The scale of the problem that births create for women is substantial, and the data tells part of the story.
In 2024, the NSW Parliamentary Inquiry into Birth Trauma received more than 4,000 submissions from women describing preventable trauma during and after labour. The report issued 43 recommendations, focusing on communication, continuity of care, informed consent and respectful treatment. The NSW Government subsequently supported 42 of those 43 recommendations.
In parallel, Birth Trauma Australia commissioned an economic analysis finding that birth injuries and ongoing conditions cost Australia $17.5 billion in financial year 2023–24. This includes $1.4 billion in direct health costs, $8.8 billion in lost work capacity, and $6.5 billion in broader burden of disease. Approximately 1.1 million Australian women are living with these conditions, affecting at least 18% of women who give birth. These aren't freak complications. They're common.
But the data alone misses something I see repeatedly in clinical practice. The women I've worked with who experienced the most physically traumatic births didn't enter labour with bodies in metabolic equilibrium. Most had histories of infertility, autoimmune disease or other chronic health conditions. Many described pregnancy symptoms suggestive of metabolic bottlenecks. Across the board, the women whose birthing experiences were most difficult also had bodies that were clearly working outside their capacity. Yet no one bothered to investigate why.
I've had mild morning sickness in my first trimester—manageable because I recognised it immediately as blood sugar dropping and ate. I've had mild reflux that responded to increasing my B vitamin intake, likely because B vitamins like B1 and B5 support acetylcholine production, and acetylcholine is what the vagus nerve runs on. And the vagus coordinates digestive processes, including those involved in certain reflux presentations. I consider myself fortunate—though not lucky—because I can spot these patterns and respond to them. Many women can't.
But here's the contradiction. I've been denied the blood work to confirm my B vitamin, copper and zinc status. Yet at every appointment, when I mention even minor symptoms, the response is immediate: "We have a medication for that. Just let me know, and I can prescribe it." So the system is willing to pay for prescriptions (which, however safe in pregnancy, still carry side effects) but not for the testing that could identify why a woman is experiencing a particular issue in the first place. Testing that is actionable, low-cost, and might prevent further complications for her and her baby.
That's not just a missed opportunity.
That's a systems failure in how we think about capacity.
What labour actually asks of the body
Recent research has sharpened how I think about the physiology of labour, and it raises questions that the current system isn't bothering to ask.
Researchers at McMaster University observed pro-inflammatory macrophages forming direct connections (tunnelling nanotubes) with uterine muscle cells. Through these connections, the macrophages transferred their own mitochondria directly into the myocytes. The transferred mitochondria significantly increased ATP production in those muscle cells and altered how the uterus metabolised progesterone—a shift critical to labour initiation.
At labour onset, your immune cells aren't just signalling. They're literally transferring energy to your uterine muscle. They’re giving it the extra resources it needs to perform a miracle that is costly to the mother on all levels, but especially energetically.
This is a fundamentally different picture of labour than the one our screening framework operates from. It's not just about obstetric risk factors. It's about metabolic capacity. If your uterus depends on receiving mitochondrial energy from immune cells, then your baseline nutritional status—your capacity to produce energy, regulate inflammation, and support cellular function—suddenly matters.
The biochemistry here isn't speculative. B vitamins participate directly in energy metabolism: B1 supports pyruvate dehydrogenase, B2 supplies FAD/FMN, B3 supplies NAD, B5 supports coenzyme A. Iron and copper are components of the electron transport chain. Magnesium participates in ATP-dependent reactions. Folate and B12 regulate homocysteine, which affects vascular function and energy metabolism. These aren't optional accessories to labour. They're infrastructure.
So here's the question we should be asking: in women with prolonged labour or difficult labour, how often do measurable metabolic or nutritional differences precede labour? Do any predict uterine performance after accounting for obstetric factors? Which women enter labour with insufficient capacity to meet its metabolic demands?
We should have answers to these questions. We don't, because no one is investigating them systematically. Instead, we're screening for a narrow band of complications while ignoring the capacity question entirely.
My own choices, and their limits
I'm also approaching the usual window for gestational diabetes screening. Australian recommendations offer a 75g oral glucose tolerance test at 24–28 weeks. I've decided to do something different.
I'll be wearing a continuous glucose monitor for 10 days to see how my body actually responds to the foods I eat in real time. Any woman can opt out of the OGTT if she wants to—it's not compulsory—but most don't know that, and most don't know what the alternatives are.
My reasons are straightforward. I don't want to consume 75g of pure glucose in a clinical waiting room while my unborn child is exposed to a large bolus of sugar untempered by fat or protein. I also don't want the disruption to my gut and my day. But more importantly, I want to understand my metabolism before there's a problem, not after. A CGM shows me how my body actually handles glucose in my actual life. If I see concerning patterns, I'll discuss them with my team and move to formal testing. But the point is to investigate mechanisms, not wait for dysfunction.
I'm already running comprehensive nutritional screening for the nutrients involved in glucose regulation and insulin resistance. If the CGM raises concerns, I'll run additional tests. I'll adjust my diet if needed, though I rarely eat the kind of foods or meals that trigger major glucose spikes. What I'm doing is proactive mechanism investigation rather than reactive diagnosis.
Now, I need to be clear about what a CGM can't do. It won't rule out an abnormal response to a glucose load. Fasting glucose and HbA1c don't establish gestational diabetes either. Fasting insulin isn't a diagnostic test. The OGTT has a specific purpose, and if my monitoring suggests I need it, I'll get it. But I'm not waiting for a diagnosis to start understanding the status of my metabolism.
Think about it like this: do you take your car to get serviced regularly, or do you wait for it to break down before replacing worn parts? I think most people go for the first option - it usually ends up being more expensive and inconvenient to fix the problem after it’s already happened. The same goes for problems that happen in your body. And, unlike cars, which you will probably own multiple of throughout your life, you (and your child) only get one body.
I do want to point out though, that my choice is a privileged one. I can access testing privately. I can read the research. I have a midwife willing to discuss alternatives. Most women can't do any of these things. And that's the real problem.
Our health system is geared towards the second option, not the first. Most of the research and advice we have tells us what to do when the breakdown has already happened, not how to prevent it from happening in the first place.
What we should be studying
I think every pregnant woman should have a comprehensive micronutrient assessment. I can't prove it yet, but based on what I see in clinical practice, I suspect many of the prolonged labours, complications, and traumatic births we encounter could be prevented or significantly improved with this information.
The research questions are straightforward, but they're not being asked systematically anywhere.
In pregnant women, how often do measurable metabolic or nutritional insufficiencies occur? Not in undernourished populations in low-income countries, but in Australia, where we have food security and yet substantial gaps in micronutrient intake remain common.
In women who experience prolonged labour, do metabolic or nutritional differences precede labour? Are women who struggle to progress underfed, undernourished, or metabolically depleted?
Do any of those differences predict uterine performance after accounting for obstetric factors?
Which tests are actually meaningful during pregnancy, and does addressing an identified insufficiency improve outcomes that matter to women themselves?
The last question is crucial. Our current research framework defaults to neonatal outcomes.
That's important.
But it's incomplete.
Women care about whether they can birth their baby, whether the experience feels within their control, whether they recover their energy and function, whether they can feed their baby, whether they have the psychological and physical resilience to handle early parenthood. Those outcomes matter as much as neonatal safety, because a mother’s wellbeing should matter. She isn’t just a vehicle for producing the next generation; she’s a person in her own right. And yes, a mother’s wellbeing is also a determinant of a baby’s wellbeing.
These aren’t competing values—they're interdependent ones.
Those studies should measure fatigue and recovery time. They should track feeding success and psychological experience. They should follow women's longer-term health, particularly pelvic floor function, sexual health, and energy capacity in the postpartum period. They should ask what actually changes women's experience of birth and recovery, not just whether babies are born alive and well.
And they should do this equitably. An expensive micronutrient assay with no clear actionable interpretation is money wasted. It's money that could go to midwifery continuity, which improves birth outcomes and costs less (which we definitely need to become more widely available, regardless). It's money that could support adequate nutrition itself—because food is the first intervention, not the last. It's money that could fund respectful communication, postnatal follow-up, or support for women's recovery. If we're going to investigate nutritional capacity, we need to do it in a way that actually serves women, not one that creates another layer of testing for those who can afford it while leaving others behind.
The research agenda isn't complex. What's missing is the will to ask whether our current framework for pregnancy care is actually optimised for maternal and fetal wellbeing, or whether it's just optimised for adequacy and risk mitigation.
Those are two very different things.
What it means to be prepared for birth
My own choices reveal a systemic failure, not just a personal preference. I can investigate my metabolic capacity because I have access, knowledge, and resources. Most women cannot. And yet the evidence I've seen in my clinical practice suggests that this investigation might actually prevent trauma and complications for many of them.
We should continue to detect pathology—gestational diabetes, anaemia, pre-eclampsia—with rigour. Those diagnoses matter. But we should ask with equal seriousness what builds capacity. What allows a woman's body to meet labour's metabolic demands? What nutritional or metabolic insufficiencies are limiting her capacity before labour even begins? What could be addressed, prevented, or optimised beforehand so that she enters birth with her body actually prepared?
Right now, we screen for complications while ignoring capacity. We're willing to medicate symptoms but not to investigate what's driving them. We've built a framework around adequacy when we should be building one around optimisation. And we've done this in a way that creates a two-tier system: women with resources can investigate what's wrong; everyone else waits until something goes catastrophically wrong.
A healthy baby and a healthy mother are not competing outcomes. They're interdependent ones. And a mother prepared for birth—metabolically, physically, psychologically—is more likely to have both.
If you want to investigate your metabolic readiness for pregnancy and birth, I work with women one-on-one to build a picture of your nutritional status, metabolic capacity, and what might need support. That might mean testing, dietary changes, supplementation, or nervous system work—usually all of them, woven together based on what your body actually tells us.