Archives of Gynecology and Obstetrics

https://doi.org/10.1007/s00404-020-05561-y

MATERNAL-FETAL MEDICINE

Does vegan diet influence umbilical cord vitamin B12, folate,

and ferritin levels?
Tomer Avnon1,2   · Ronit Anbar3,4 · Inbar Lavie2 · Tali Ben‑Mayor Bashi1 · Efrat Paz Dubinsky3 · Sivan Shaham3 ·
Yariv Yogev1,2

Received: 2 March 2020 / Accepted: 20 April 2020

© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Purpose  To determine the influence of maternal diets on maternal and umbilical cord blood levels of vitamin B12, folic
acid, ferritin, and hemoglobin.
Methods  A prospective observational study on women who maintained the same diet for at least 3 months prior to, and
throughout current pregnancy. Women were divided according to their diet. Diet questionnaires were filled in during the 3rd
trimester. Blood samples for complete blood counts and levels of ferritin, vitamin B12, folate, and albumin were taken from
the women prior to delivery and from the umbilical cord immediately after delivery.
Results  The 273 enrolled women included 112 omnivores, 37 pescatarians, 64 vegetarians, and 60 vegans. There were no
significant differences in the maternal B12 levels between the study groups (P = 0.426). Vegans had lower maternal fer-
ritin levels compared to pescatarians (27 ± 17 vs 60 ± 74 ng/ml, respectively, P = 0.034), but not compared to vegetarians
(P = 0.597), or omnivores (P = 1.000). There were no significant differences in the umbilical cord B12, folate, ferritin, and
hemoglobin levels between the study groups. A sub-analysis that compared women who consumed multivitamins, B12
and iron supplements during pregnancy to women who did not, revealed differences in the levels of umbilical-cord B12
(1002 ± 608 vs 442 ± 151 pg/ml, respectively, P = 0.000) and maternal blood B12 (388 ± 209 vs 219 ± 95 pg/ml, respectively,
P = 0.030) only among vegans, but not among omnivores.
Conclusion  Vegan diet does not change the umbilical cord levels of B12, folic acid, ferritin, and hemoglobin. Vegans who
do not take any vitamin supplementation are at greater risk for B12 deficiency than omnivores.

Keywords  Anemia · B12 · Folic acid · Micronutrient · Plant-based food · Vitamin deficiency

The findings were presented at the 40th annual pregnancy meeting
of the Society for Maternal Fetal Medicine, Grapevine, Texas, US,
February 3–8, 2020.
* Tomer Avnon
Tomer.avnon@gmail.com
1 plant-based products and free of all dairy products and eggs
Department of Obstetrics and Gynecology, Lis Maternity
and Women’s Hospital, Tel‑Aviv Sourasky Medical Center,
Affiliated to the Sackler Faculty of Medicine, Tel-Aviv
University, 6 Weizmann Street, 6423906 Tel‑Aviv, Israel
2
Sackler Faculty of Medicine, Tel-Aviv University, Tel‑Aviv,
Israel
3
Nutrition and Dietetic Unit, Tel‑Aviv Sourasky Medical
Center, Affiliated to the Sackler Faculty of Medicine,
Tel-Aviv University, Tel‑Aviv, Israel
4
The Robert H Smith Faculty of Agriculture, Food
and Environmental Quality Sciences, School of Nutritional
Sciences, Hebrew University, Jerusalem, Israel
Introduction
The prevalence of people who choose to maintain a vegan
and a vegetarian diet and abstain from any animal-based
food has been steadily increasing [1]. A vegan diet is distin-
guished from a vegetarian diet by being strictly limited to
[2]. A vegan diet may lead to potential nutritional deficits,
including vitamins B12 [1–7], B2 [4], and D [1, 5, 6], as
well as calcium [1, 2, 6], iron, zinc [6], and even iodine [7].
The maternal diet during pregnancy reportedly could
have an effect on the newborn bone mass later in life [8],
on insulin resistance, and on changes in lipid ratio in the
umbilical cord [9]. Few studies have examined the effect of
a vegan diet on pregnancy outcome and on potential related
complications [10–12], though, those studies focused on
vegetarians or on women in the general population, and not

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on women who followed the stringent regulations of a vegan
diet. Vegans have been found to be at increased risk for defi-
ciencies in vitamin levels, such as B12 and D, and in micro-
nutrients, such as iron, zinc, iodine, and calcium [1–7]. As a
result, it was considered that the newborns of those women
may suffer from similar deficiencies [10, 11]. Most of our
knowledge about the influence of low B12 levels in infancy
is based upon maternal depletion [13]. Specifically, low lev-
els of maternal B12 may cause failure to thrive, irritability,
and reduced cerebral growth. They may also be associated
with increased risk for neural tube defects and low verbal
performance [13, 14]. Since there is no reliable plant-based
food source for B12, several guidelines recommend vegan
women to receive adequate B12 supplementation and nutri-
tional counselling [15, 16].
The purpose of our study was to prospectively deter-
mine the influence of vegan, vegetarian, pescatarian, and
omnivore maternal diets on maternal blood levels and on
umbilical cord levels of vitamin B12, folic acid, ferritin and
hemoglobin.
Methods
Study design
The study was approved by the local institutional review
board (0715-17-TLV) and all women provided written
informed consent. This was a prospective observational
study of women who gave birth in a tertiary, university-
affiliated medical center between May 2018 and June 2019.
Eligibility was limited to women aged 18 years or more
with a singleton pregnancy. Only women who maintained
the same diet for at least 3 months prior to and through-
out current pregnancy were enrolled. The exclusion criteria
were women with medical indications for a specific restric-
tive diet, such as pre-gestational diabetes mellitus, celiac,
lactose intolerance, and inflammatory bowel disease, and
women after bariatric procedures or other bowel resections.
The participants were divided into 4 groups according to
their diet: vegans who consume only plant-based products,
vegetarians who consume mainly a plant-based diet but also
include dairy products and eggs, pescatarians who consume
fish products in their vegetarian diet, and omnivores who
consume animal-based and plant-based products. All women
were asked to fill eating questionnaires during their 3rd tri-
mester of pregnancy.
Sample size analysis: Our main hypothesis was that
vegans will have lower maternal and umbilical B12 levels.
We calculated a sample size of 32 women in each group
with a power of 80%, based on past studies’ B12 difference
of 23–56% between vegans to omnivores [4–6].
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Archives of Gynecology and Obstetrics
Maternal blood tests were taken prior to delivery for com-
plete blood count and levels of ferritin, vitamin B12, folic
acid and albumin. Umbilical cord blood tests were taken
immediately after delivery for levels of hemoglobin, ferritin,
vitamin B12, and folic acid. Data were extracted from the
real-time computerized database and from the filled-in ques-
tionnaires whose items included eating habits and length
of following a specific diet, maternal age, gravidity, parity,
background medical information, data regarding vitamins
and supplementations taken throughout pregnancy, body
mass index (BMI) at the time of conception, weight gain
during pregnancy, and mode of conception (either spontane-
ous or artificial reproductive techniques).
Biochemical analysis
Vitamin B12, folic-acid and ferritin levels were measured
in blood plasma using a commercial immunoassay (ADVIA
Centaur, Siemens Healthcare GmbH, Germany). Iron levels
were measured in blood plasma (ADVIA, Siemens Health-
care GmbH, Germany). Albumin levels were measured by
BCG dye binding (ADVIA, Siemens Healthcare GmbH,
Germany). Hemoglobin concentrations were measured by
DxH 800 Hematology Analyzer (Beckman Coulter, CA,
US). Umbilical cord folate values < 3 ng/ml [17], vitamin
B12 concentrations < 200 pg/ml [1, 17], and ferritin con-
centrations < 76 ng/ml [18] were classified as insufficient.
Neonatal anemia was defined as umbilical cord hemoglobin
levels < 13 g/dL [19].
Data analysis
Descriptive statistics of demographic and laboratory results
were generated by the type of diet. Differences between the
selected parameters were evaluated by one-way ANOVA,
chi-squared, and Fisher’s exact test. A sub-analysis was
performed to evaluate a possible influence of vitamin sup-
plementation: women who consumed multivitamins, iron,
and/or B12 supplementation were compared to women who
did not consume any supplementation. Differences between
the selected parameters were evaluated by t tests. A P value
of 0.05 was considered statistically significant. Statistical
analysis was performed with IBM SPSS statistics version
26 (Chicago, IL, USA).
Results
During the study period, 273 women were enrolled and met
the inclusion criteria, which included 112 (41.03%) omni-
vores, 37 (13.55%) pescatarians, 64 (23.44%) vegetarians,
and 60 (21.98%) vegans. The participants’ demographical
characteristics are provided in Table 1. Vegan women were
Archives of Gynecology and Obstetrics

older and had a significantly lower mean pre-gestational
BMI compared to the other groups (Table 1).
Maternal and umbilical cord blood tests measurements
are summarized in Table 2. For the maternal blood meas-
urements, only ferritin levels were significantly different
between the groups (P = 0.029). Vegans had lower mater-
nal ferritin levels compared only to pescatarians (27 ± 17 vs
60 ± 74 ng/ml, respectively, 95% CI − 62.776 to − 1.524,
P = 0.034), but not compared to vegetarians (44 ± 73 ng/
ml, 95% CI − 43.564 to 10.165, P = 0.597) or omnivores
(34 ± 45 ng/ml, 95% CI − 29.279 to 16.191, P = 1.000).
For the umbilical cord blood tests, there were no significant
differences in B12, folic acid, ferritin, or hemoglobin lev-
els between the study groups (Table 2). There were no diet
group differences in the rates of maternal anemia, neonatal
anemia, or in the rates of low umbilical B12, ferritin or folic
acid levels (Table 3).
During pregnancy, 30 women received nutritional con-
sultation (vegans 13.33%, vegetarians 6.25%, pescatarians
10.81% and omnivores 12.50%). We did not find any influ-
ence for nutritional consultation during pregnancy on the
measured outcomes.
We performed a sub-analysis comparing women who con-
sumed multivitamins, B12, and/or iron supplements during

Table 1  Maternal demographics according to diet

Vegan Vegetarian Pescatarian Omnivore P value
n = 60 n = 64 n = 37 n = 112 (α = 5%)

Age (years) 34.97 ± 3.85 33.56 ± 4.13 32.62 ± 3.63 32.56 ± 4.02 0.010
 BMI 21.41 ± 2.63 23.51 ± 3.42 21.82 ± 2.93 22.56 ± 3.32 0.020
 Parity [n (%)]
  Nullipara 29 48.33% 35 54.69% 24 64.86% 66 58.93% 0.374
  Para 1–2 28 46.67% 24 37.50% 11 29.73% 42 37.50% 0.400
  Para 3 +  3 5.00% 5 7.81% 2 5.40% 4 3.57% 0.637
Use of ART, n (%) 12 20.00% 11 17.19% 4 10.81% 10 8.93% 0.162

BMI body mass index at pregnancy onset, ART​artificial reproductive techniques

Table 2  Maternal and umbilical Vegan Vegetarian Pescatarian Omnivore P value

cord blood measurements
according to diet n = 60 n = 64 n = 37 n = 112 (α = 5%)

Maternal
 Hemoglobin (g/dL) 12.24 ± 1.04 12.22 ± 0.90 12.07 ± 1.30 12.39 ± 1.08 0.406
 Ferritin (ng/ml) 27.71 ± 17.37 44.41 ± 72.53 59.86 ± 73.70 34.26 ± 44.97 0.029
 B12 (pg/ml) 361.37 ± 204.76 378.94 ± 282.85 375.78 ± 301.33 325.84 ± 151.53 0.426
 Folic acid (ng/ml) 15.55 ± 7.57 15.51 ± 6.12 14.10 ± 5.12 14.33 ± 6.37 0.536
 Albumin (g/L) 35.49 ± 3.32 36.55 ± 1.93 35.54 ± 2.66 36.52 ± 2.47 0.080
Umbilical
 Hemoglobin (g/dL) 15.56 ± 2.21 15.98 ± 1.99 15.49 ± 1.76 15.76 ± 2.23 0.703
 Ferritin (ng/ml) 199.02 ± 120.87 200.86 ± 142.46 257.98 ± 144.72 233.26 ± 216.80 0.453
 B12 (pg/ml) 902.05 ± 586.60 832.21 ± 469.80 778.89 ± 481.94 778.57 ± 402.04 0.573
 Folic acid (ng/ml) 20.51 ± 4.66 20.45 ± 4.10 18.73 ± 4.01 20.61 ± 5.01 0.677

Table 3  Deficiencies in Characteristic Vegan Vegetarian Pescatarian Omnivore P value

maternal and umbilical cord
blood levels according to diet (α = 5%)

Maternal anemia 10.00% 6/60 9.37% 6/64 8.11% 3/37 8.04% 9/112 0.969
Maternal B12 deficiency 17.54% 10/57 12.25% 6/49 18.75% 6/32 9.26% 10/108 0.347
Umbilical anemia 8.33% 4/48 0.00% 0/52 3.45% 1/29 5.10% 5/98 0.167
Umbilical ferritin deficiency 7.32% 3/41 11.36% 5/44 4.35% 1/23 14.12% 12/85 0.561
Umbilical B12 deficiency 5.00% 2/40 0.00% 0/39 0.00% 0/19 1.23% 1/81 0.504
Umbilical folic acid deficiency 0.00% 0/20 0.00% 0/23 0.00% 0/11 1.67% 1/60 1.000

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pregnancy to women who did not consume any supplements
(Table 4). There was a significant difference between vegans
who consumed to vegans who did not consume any sup-
plements, in the levels of umbilical cord B12 (1002 ± 608
vs 442 ± 151 pg/ml, respectively, 95% CI 312.986–807.121,
P < 0.001) and in the level of maternal blood B12 (388 ± 209
vs 219 ± 95 pg/ml, respectively, 95% CI 16.708–320.625,
P = 0.030). There was no significant difference in the lev-
els of maternal B12 levels (95% CI − 61.512 to 137.546,
P = 0.450) or umbilical cord B12 levels (95% CI − 91.887
to 563.835, P = 0.156) between the omnivores who did or
did not consume any supplements. Since only 2 vegetarians
and 2 pescatarians did not consume any supplements, we
could not compare the influence of supplement use for those
groups (Table 4).
Discussion
In this study, we aimed to examine the influence of 4 types of
maternal diets on maternal and umbilical cord blood levels
of vitamin B12, folic acid, ferritin and hemoglobin, with
emphasis on the specific comparable effect of the vegan
diet. Our main findings were fourfold. (1) Vegan diet did
not affect maternal blood levels of B12, folic acid, albu-
min, or hemoglobin, and only the ferritin level was lower
among vegans in comparison to pescatarians. (2) Vegan diet
did not affect umbilical cord blood levels of B12, ferritin,
folic-acid, or hemoglobin. (3) There was no difference in
the rate of maternal or neonatal anemia or in the rate of low
umbilical B12, ferritin, or folic acid levels between any of
the 4 diet groups. (4) Only the vegan women who did not
take any supplements during pregnancy had lower maternal
and umbilical B12 levels in comparison to vegans who con-
sumed supplements.
Overall, the vegan women in our study cohort did not
differ in their B12 or folic acid levels from the other 3 diet
groups. This finding is in opposition to the findings of oth-
ers [4–6], which demonstrated lower B12 and higher folic
acid [4] levels among vegans compared to omnivores. Those
studies, however, compared vegans and omnivores in the
general population and did not focus on pregnant women.
Table 4  B12 measurements
according to oral
supplementation
Vegan
 Maternal B12 (pg/ml)
 Umbilical B12 (pg/ml)
Omnivore
 Maternal B12 (pg/ml)
 Umbilical B12 (pg/ml)
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Archives of Gynecology and Obstetrics
It is possible that such differences disappear as a result of
the commonplace use of vitamin supplementation among
pregnant women compared to nonpregnant women. Inter-
estingly, only the ferritin level was lower among our vegan
group and only in comparison to pescatarians. Though, we
do not think this difference has any clinical implication
since its levels were within normal range and no differences
were found in all other measurements. As far as we know,
no study mentioned ferritin levels among pregnant vegan
women, although the review of Piccoli et al. [10] did men-
tion lower ferritin levels among pregnant vegetarians with a
higher incidence of anemia.
We did not find any effect of the maternal diet on umbili-
cal cord laboratory measurements. As far as we know, the
question of a vegan diet’s effect on umbilical hemoglobin,
B12, or folic acid levels has not been addressed before. The
fact that we did not find any difference in the maternal-blood
groups for most of the measurements, is in the concordance
of this finding.
Our findings of similar rate of anemia and B12 defi-
ciency among different maternal diets are supported by sev-
eral studies that did not demonstrate a higher prevalence of
anemia among pregnant [1] and non-pregnant [6] vegans.
Additionally, Chebaya et al. [20] reported a similar rate of
maternal B12 deficiency among women who consumed vita-
mins and those who did not. Unlike earlier reports, however,
the rate of maternal B12 deficiency (< 200 pg/ml) in our
vegan group was much lower (18%) than the rate reported
by others (38%) [1].
Since the source of B12 is mainly in animal-based food,
some vegetarians or vegans are at increased risk for B12
deficiency, such as women with intestinal diseases and
decreased B12 absorption. The transport of B12 to the fetus
is diminished in women with low levels of B12 [14], where-
upon their children may have B12 deficiency [10, 11]. Those
studies support our findings of there being a direct relation
between maternal B12 levels and umbilical cord B12 levels,
and the contention that vegans who do not consume sup-
plements have lower maternal and umbilical blood levels.
Although the levels of our study vegans were still inside
the lower-normal range (> 200 pg/ml). In contrast to our
findings, several studies demonstrated higher maternal B12
Multivitamins + iron sup- No multivitamins or iron P value (α = 5%)
plementation supplementation
n = 51 n = 8
388.29 ± 209.54 219.63 ± 95.26 0.030
1002.63 ± 608.56 442.57 ± 151.30  < 0.001
n = 91 n = 11
330.47 ± 163.16 292.45 ± 82.22 0.450
794.55 ± 423.69 558.57 ± 282.96 0.156
Archives of Gynecology and Obstetrics
levels in the general pregnant population who consume B12
supplementation during pregnancy [20, 21] and postpartum
[22]. Importantly, those studies enrolled women in India
[21], Cambodia [20], and Bangladesh [22], and they did
not relate specifically to vegan or vegetarian populations,
even though many of those countries’ populations consume
mainly plant-based diets.
Newborns with B12 deficiency may sustain several seque-
lae such as failure to thrive, irritability, reduced cerebral
growth, apathy, and future interference with verbal perfor-
mance [6, 13, 14]. Since maternal B12 depletion may be the
reason for many of those cases [13], several guidelines are
in place that recommend vegan women receive nutritional
counselling and to check regularly for critical B12 levels and
nutritional deficiencies [15, 16].
The strengths of our study are that it is one of the largest
on umbilical cord measurements that focused specifically on
a vegan population; unlike many earlier studies that com-
bined vegans and vegetarians together, or that covered the
general population, our study emphasized this population
and differed this group from vegetarians and from pescatar-
ians as well. We prevented contamination of the results by
restricting the study only to women who followed the same
diet for at least 3 months prior to their pregnancy and main-
tained it until delivery. Finally, we recruited women during
different stages of their pregnancy to maintain heterogenicity
and to prevent selection bias.
Our study has some limitations that bear mention.
Although we performed many efforts to attain all the blood
tests, several tests went missing due to miscellaneous rea-
sons. We also excluded women who began their pregnancy
in a vegan or vegetarian diet and changed it through the
course of it. Thus, we cannot know if there is a specific point
in pregnancy in which a change in diet might influence the
outcomes.
In conclusion, a pregnant woman’s following a vegan
diet does not affect the umbilical cord blood levels of B12,
folic-acid, ferritin, or hemoglobin. However, the B12 levels
of pregnant vegan women who do not take any vitamin sup-
plementation are much more affected than omnivores. We,
therefore, recommend that the B12 levels of pregnant vegan
women should be monitored and that these women should
be encouraged to take vitamin supplementation.
Author contributions  TA conception, methodology, investigation
supervision, data curation, formal analysis and drafting the initial
manuscript. RA methodology and investigation. ILa formal analysis.
TB-MB investigation and data curation. EPD investigation and data
curation. SS investigation and data curation. YY methodology, inves-
tigation supervision and resources.
Funding  The study was self-funded by the deportment and no external
funding was received.
Compliance with ethical standards 
Conflict of interest  All the authors report no conflicts of interest.
Ethical approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Hel-
sinki declaration and its later amendments or comparable ethical stand-
ards. Informed consent was obtained from all individual participants
included in the study.
Informed consent  This article does not contain any studies with ani-
mals performed by any of the authors.
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