BJOG: an International Journal of Obstetrics and Gynaecology

August 2002, Vol. 109, pp. 905– 908

Vitamin D deficiency in pregnant women from a non-European

ethnic minority population—an interventional study
S. Datta, M. Alfaham*, D.P. Davies, F. Dunstan, S. Woodhead, J. Evans, B. Richards
Objective To determine the vitamin D status of pregnant women from non-European ethnic minorities in
South Wales.
Design Prospective study.
Setting Llandough Hospital, Cardiff, South Wales.
Sample One hundred and sixty pregnant women from a non-European ethnic minority population in South
Wales.
Methods Biochemical screening of vitamin D status was carried out at the first antenatal visit. Women found
to be deficient in vitamin D were subsequently supplemented and vitamin D status was rechecked at
delivery.
Main outcome measure Vitamin D status at delivery.
Results Eighty of 160 women had a vitamin D level below 8 ng/mL at their first antenatal visit and were
treated with oral vitamin D. Factors that could influence vitamin D status such as religion, fluency in
English and dressing habits did not appear to have any effect, although a higher proportion of women who
had lived in Britain for longer than three years had subnormal vitamin D levels. In 58 of those checked at
delivery, the mean plasma vitamin D level increased from 6 to 11 ng/mL although the mean parathyroid
hormone level was unchanged.
Conclusion In view of the high incidence of subnormal vitamin D levels in women from ethnic minorities, we
recommend biochemical screening of these women in early pregnancy, with subsequent supplementation
where indicated.

INTRODUCTION (vitamin D) below 25 nmol/L, a value considered to

Some ethnic minority groups in Britain, especially those
who have their origins in the Indian subcontinent and
Africa, are more vulnerable to vitamin D deficiency1 – 3.
As well as increased skin pigmentation, several other
factors contribute to this vulnerability. These include wear-
ing clothes that restrict exposure to sunlight4, spending a
limited time outdoors and vegetarian diets2.
The Department of Health has long recognised the need
to supplement infants, young children and pregnant women
from Asian families with vitamin D5. However, despite
considerable medical evidence, supplements are still not
given routinely to these groups, neither is there a structured
screening programme. Sporadic cases of florid rickets
continue therefore to be reported in children from these
ethnic minority populations6. A recent survey7 carried out
by the social survey division of the Office for National
Statistics found that between 20% and 34% of children
from these groups had values of 25-hydroxycholecalciferol
Llandough Hospital, Cardiff, South Wales, UK
* Correspondence: Dr M. Alfaham, Department of Child Health,
Cardiff & Vale NHS Trust, Llandough Hospital, Penarth, Cardiff CF64
2XX, UK.
D RCOG 2002 BJOG: an International Journal of Obstetrics and Gynaecology
PII: S 1 4 7 0 - 0 3 2 8 ( 0 2 ) 0 1 1 7 1 - 0
indicate deficiency. A previous study performed in Cardiff
using raised parathyroid hormone as an indicator of
vitamin D deficiency found that 6 of 32 Asian pregnant
women in early pregnancy and 6 of 19 Asian women tested
at delivery had high parathyroid hormone levels8.
To establish further the extent of the problem in our
catchment area and to be able to set up recommendations
for vitamin D supplementation locally, we implemented an
interventional programme at an antenatal clinic in South
Wales between April 1995 and April 1996.
METHODS
Pregnant women were identified at their booking visit
if they belonged to the following ethnic minority groups:
African, Afro-Caribbean, Asian, Far-Eastern, Middle-
Eastern.
Written information in different languages was provided
regarding the need for adequate vitamin D status and the
purpose of the project. Blood samples were taken from
these women at the booking clinic for levels of parathyroid
hormone and vitamin D. A record was made of the
women’s dressing habits, ability to speak English, their
religion and the duration of their living in Britain.
www.bjog-elsevier.com
906 S. DATTA ET AL.

Table 1. Number of pregnant women from each ethnic group whose parathyroid hormone, calcium, phosphate and alkaline
vitamin D was tested and percentage treated. phosphatase from women on supplements, and their general
Ethnic origin No. of women Percentage treated practitioners notified if further supplementation was neces-
sary. Every effort was made to improve compliance.
Indian subcontinent 100 52
Besides providing written information, the midwives also
Afro-Caribbean 4 25
Middle East 9 22 made it a point to remind women to take supplements at
Far East 11 9 each visit, be it in hospital or at home.
Africa 36 67

Parathyroid hormone was measured by an immuno-
chemiluminometric assay (Magic Lite PTH; Chiron Diag-
nostics, Halstead, Essex, UK). The inter-assay coefficient
of variation at a concentration of 43.6 pmol/L was 11.3%.
25-Hydroxycholecalciferol was measured by radio-
immunoassay (Incstar, MN 55082, USA). The inter-assay
coefficient of variation at a concentration of 53.7 ng/mL
was 11.0%.
A vitamin D level <8 ng/mL (<20 nmol/L) was taken as
the cutoff value for commencing calciferol 800 IU/day. At
36 weeks, all women with low or borderline vitamin D
levels were re-tested and if the levels still remained unsat-
isfactory, the supplements were increased to 1600 IU/day.
Finally, at delivery, blood was taken for vitamin D,
RESULTS
One hundred and sixty consecutive pregnant women
were recruited from ethnic minority groups. Eighty women
(50%) had vitamin D levels <8 ng/mL and were treated
with oral vitamin D. Table 1 shows the percentage of
treated women from each ethnic group.
Figure 1 shows the relationship between parathyroid
hormone and vitamin D levels in 144 women at booking.
While parathyroid hormone was elevated in some women
with presumed vitamin D deficiency, 65 of the 80 women
(81%) with low vitamin D levels had parathyroid hormone
levels within the normal adult reference range (<5.6 pmol).
Vitamin D and parathyroid hormone levels were
rechecked at delivery in 58 of the 80 women (73%).

30

20

10
9
8
Vitamin. D at booking

7
6

4
.6 .8 1 2 4 6 8 10 20 40

Parathyroid hormone at
booking

Fig. 1. Levels of serum parathyroid hormone and vitamin D at booking in 144 women.

D RCOG 2002 Br J Obstet Gynaecol 109, pp. 905 – 908

 VITAMIN D DEFICIENCY IN PREGNANT WOMEN FROM ETHNIC MINORITIES
Table 2. Serum vitamin D and parathyroid hormone levels at delivery in
58 out of 80 women who were treated with oral vitamin D supplements
during pregnancy.
Vitamin D Vitamin D Parathyroid hormone
at booking post-delivery
At booking Post-delivery
Mean 5.79 11.24 3.69 4.06
SD 0.91 6.34 2.78 3.17
The mean level of vitamin D increased from 6 to 11 Ag/mL,
but the mean parathyroid hormone level remained the same
(Table 2).
Vitamin D levels returned to normal in 35 of the 58
women (60%) checked at delivery. It was not possible to
ascertain the compliance of the women. In all the 58
women, the calcium, phosphate and alkaline phosphatase
levels were within normal limits.
Other factors influencing vitamin D status such as
religion, fluency in English and dressing habits did not
appear to affect vitamin D levels. However, 50% of the
women who had been in Britain for longer than three years
had subnormal vitamin D levels, compared with 25% of
those who have lived in Britain for less than three years and
25% of those who were born in Britain.
DISCUSSION
Our findings confirm results from an earlier study
showing a large number of women from ethnic minority
populations in the Cardiff area to be subclinically defi-
cient in vitamin D8. The same was not found in pregnant,
white, Caucasian women. Although low vitamin D status
seldom causes florid maternal osteomalacia9 – 12, it has
been associated with maternal ill health especially during
pregnancy and lactation, with symptoms including muscle
and joint pains, poor appetite and general apathy and
weakness, as well as neonatal rickets with fits and
stridor7, hypocalcaemia13,14, heart disease15, slow growth
during the first year of life3,16,17 and hypoplasia of the
enamel of primary teeth18. Hence, it seems prudent to
give vitamin D supplementation to all pregnant women
from ethnic minorities. This has been the recommendation
of the Department of Health for more than 20 years,
although it is not widely practised.
Vitamin D is toxic in large doses. Cases of hypervitami-
nosis D have been reported in individuals whose vitamin D
intake was 70 – 600 times higher than the recommended
400 IU/day19, but there have also been cases of infantile
hypercalcaemia caused by a moderate increase in vitamin D
intake20. It seems justified to screen all individuals before
supplementation.
More research is needed to establish the most accept-
able, efficient and cost-effective way of vitamin D sup-
plementation. Nevertheless, daily supplementation with
D RCOG 2002 Br J Obstet Gynaecol 109, pp. 905 – 908
907
400– 1000 IU/day of vitamin D for those that are found
to be deficient seems safe21. However, this policy requires
good compliance. Poor compliance is reflected in our
study, as vitamin D levels returned to normal only in 35
out of 58 women who were tested at delivery.
Controversy still exists regarding the effects of preg-
nancy on circulating maternal parathyroid hormone levels
and its value as a screening test. Although there is now
considerable data indicating that plasma levels of para-
thyroid hormone rise with poor vitamin D status, this may
not be true for pregnancy. Studies using a new immuno-
radiometric assay for parathyroid hormone have reported
a decline in parathyroid hormone levels during preg-
nancy22,23. Circulating levels of 1,25-dihydroxycholecalci-
ferol have consistently been shown to be elevated during
pregnancy due to placental synthesis24,25, and this hormone
has been suggested as the primary mediator of changes in
maternal calcium metabolism. Our study also demonstrated
a weak association between plasma levels of parathyroid
hormone and vitamin D (Fig. 1). This has been reported
previously26,27 and suggests that circulating parathyroid
hormone on its own is inappropriate as a test of vitamin D
status during pregnancy. Hence, it seems that both
vitamin D as well as parathyroid hormone levels should
be estimated in order to screen for vitamin D deficiency
during pregnancy.
In the 1970s, several studies suggested how best to
improve vitamin D status in Asian mothers and their
newborn infants living in Britain. Brooke et al.3, in a
double-blind trial of vitamin D supplements in pregnant
Asian women, administered 1000 units of ergocalciferol
per day to 59 women and placebo to 67 controls during
the last trimester. Mothers in the treatment group gained
weight faster and at term they and their infants all had
adequate plasma 25-hydroxycholecalciferol concentra-
tions; infants in the control group had larger fontanelles,
and five had symptomatic hypocalcaemia. The same
workers also demonstrated improved postnatal growth
in infants whose mothers received a supplement of
vitamin D16,17.
The Department of Health5,20 has recommended that
measures should be taken to improve awareness among
the public as well as doctors and midwives regarding the
need to achieve adequate vitamin D status during preg-
nancy in women from ethnic minorities. We undertook our
interventional project in the light of evidence of poor
compliance from several previous studies. Screening these
women during their first antenatal visit with subsequent
supplementation where appropriate seems a satisfactory
and safe approach.
Acknowledgements
We thank Mrs Hayley Phillips for administrative super-
vision throughout the study.
908 S. DATTA ET AL.

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