Micronutrient Intake, Supplementation Practices and Lifestyle Among Pregnant Women in Greece: A Review

Abstract

Adequate nutrition and healthy behaviours during pregnancy are essential to maternal and neonatal health. Evidence from Greece on maternal dietary and lifestyle practices remains limited, despite global guidelines promoting supplementation, physical activity (PA) and abstinence from harmful substances. This review evaluates micronutrient intake, supplementation practices, PA and substance exposure among pregnant women in Greece, based on studies from 2010 to 2025. The results reveal widespread use of supplements, but frequent deviations from clinical guidelines. Suboptimal intake of key micronutrients remains common, and unsupervised supplementation raises concerns about excessive intake. Caffeine and tobacco use persist during pregnancy and lactation, while alcohol consumption shows a declining trend. PA is generally below international recommendations, with most pregnant women engaging in sedentary or low-intensity activities. These findings underscore systemic gaps in antenatal care in Greece, including inconsistent counselling, lack of structured screening and the absence of coordinated national strategies. Culturally tailored public health interventions, with a focus on equitable access and behaviour change support, are urgently needed to enhance nutritional adequacy, reduce behavioural risks and promote evidence-based care across the perinatal period.

1. Introduction

Adequate maternal nutrition during pregnancy is essential for optimal fetal development, maternal well-being and long-term health outcomes for both mother and child [1,2]. Among the critical nutritional elements, vitamins and minerals play indispensable roles in supporting physiological processes such as cellular proliferation, placental function, and immunological adaptations [3,4]. Deficiencies in key micronutrients are consistently linked with adverse perinatal outcomes, such as intrauterine growth restriction, preeclampsia, preterm birth, congenital malformations and developmental impairments [5,6,7].

Folate, for example, is necessary for nucleotide biosynthesis and methylation, and its deficiency is a well-known risk factor for neural tube defects (NTDs), during the first 28 days of gestation [8]. Iron supports erythropoiesis and oxygen transport, with iron-deficiency anemia associated with low birth weight, preterm delivery and impaired maternal cognitive and physical performance [9]. Vitamin D regulates calcium homeostasis and immune function, with low maternal levels associated with increased risks of gestational diabetes, preeclampsia and impaired fetal skeletal development [10]. Similarly, iodine is crucial for thyroid hormone synthesis and fetal neurodevelopment, while its deficiency remains the leading cause of preventable intellectual disability worldwide [11].

While global health authorities recommend routine supplementation of certain micronutrients during pregnancy, such as folic acid, iron and vitamin D, the degree of supplementation and adherence to guidelines varies significantly across populations and settings [12,13]. Factors including socioeconomic status, healthcare access, cultural norms and national policy implementation contribute to these disparities [14].

Beyond micronutrient intake, maternal lifestyle factors such as physical activity, tobacco use, alcohol consumption and caffeine intake also significantly influence pregnancy outcomes [15,16,17]. Even low-to-moderate alcohol exposure may affect fetal neurodevelopment [18], while excessive caffeine intake is associated with increased risk of miscarriage and intrauterine growth restriction [19]. Maternal tobacco use remains a persistent concern, contributing to placental dysfunction and elevated risks of stillbirth and neonatal morbidity [20]. Despite public health recommendations, consumption of these substances is rather high among pregnant women, often due to a lack of awareness or inconsistent guidance from healthcare providers [21,22].

Conversely, physical activity is well-documented to promote maternal and fetal health. The American College of Obstetricians and Gynecologists (ACOG) recommends at least 30 min of moderate-intensity activity on most days of the week. Physical activity during pregnancy has been shown to positively influence maternal weight management, glycemic control, and psychological well-being [23]. However, despite these benefits, studies indicate that pregnant women spend over 50% of their time in sedentary behaviour, often due to perceived barriers, fatigue, or insufficient guidance [24].

Despite global consensus on the importance of maternal nutrition and lifestyle during pregnancy, Greece remains underrepresented in targeted health research. This is particularly concerning given the region’s ongoing nutritional and behavioural transitions. Recent data show a progressive shift away from the traditional Mediterranean diet, characterized by high consumption of vegetables, legumes, and healthy fats, toward more Westernized dietary patterns rich in ultra-processed, nutrient-poor foods [25,26].

Compounding these challenges, Greece’s prolonged socioeconomic crisis has contributed to increased food insecurity, reduced access to prenatal care and widened health inequalities [27,28,29]. These systemic issues may significantly impair the ability of pregnant women to meet nutritional recommendations or maintain healthy behaviours. Additionally, national-level antenatal supplementation policies in Greece remain fragmented, lacking the unified implementation observed in some Northern and Western European countries [30].

To date, no comprehensive review has evaluated the interplay between micronutrient intake, supplement use, physical activity and substance exposure (tobacco, alcohol, and caffeine) in the Greek maternal population. Given the growing global emphasis on context-specific, equity-driven maternal health interventions [6], a robust, country-specific synthesis is both timely and necessary.

This review seeks to address this gap by analyzing recent evidence assessing patterns in vitamin and mineral intake and underlying structural or systemic barriers influencing maternal nutrition and health behaviours in Greece. To ensure conceptual clarity and coherence, the review is organized into thematic sections addressing: (i) maternal micronutrient intake and supplementation practices; (ii) behavioural risk factors, including tobacco, alcohol, and caffeine use during pregnancy and lactation; (iii) physical activity patterns and their determinants and (iv) systemic and policy-level influences on maternal nutrition and health behaviours. The review concludes with an analysis of public health implications and outlines key priorities for future research and practice. By providing a comprehensive synthesis of existing evidence, this review seeks to inform future nutritional policies, clinical guidelines and public health strategies to improve perinatal outcomes within the Greek context.

2. Materials and Methods

This review presents a structured synthesis of peer-reviewed literature assessing micronutrient intake, supplementation practices, physical activity and lifestyle behaviours among pregnant women in Greece. The aim was to identify patterns, gaps and implications for public health and antenatal care.

A comprehensive literature search was conducted in PubMed and Scopus, covering the period January 2010 to October 2025. The search strategy employed combinations of terms related to pregnancy, maternal nutrition, supplementation, physical activity and substance use. Broader terms (e.g., “pregnancy,” “maternal health,” “micronutrients,” “supplementation,” “vitamins,” “minerals,” “physical activity,” “lifestyle,” “health behaviour”) were combined with specific terms (“folic acid,” “vitamin D,” “iron,” “iodine,” “caffeine,” “alcohol,” “tobacco”) and the geographic filter “Greece.” Boolean operators and Medical Subject Headings (MeSH) were used where applicable to refine results.

Studies were included if they (a) were conducted in Greece or used Greek population samples; (b) focused on pregnancy-related dietary intake, supplementation, substance use, or physical activity; (c) were published in English in peer-reviewed journals and (d) employed observational or implementation study designs (e.g., cross-sectional, cohort, or intervention). Studies were excluded if they were reviews, editorials, animal studies, or did not specifically address pregnancy or maternal health.

After screening titles and abstracts, full texts were reviewed for eligibility. A total of 20 studies met the inclusion criteria and were analyzed thematically. Extracted data included study design, population characteristics, outcome measures and implications. Findings were grouped under key thematic areas: micronutrient intake and supplementation, substance use (tobacco, alcohol, caffeine) and physical activity practices.

3. Review of Findings

This section presents a thematic synthesis of the included literature, structured around key domains relevant to maternal health behaviours during pregnancy in Greece. These include micronutrient intake and supplementation practices, substance use and physical activity patterns. Each theme is explored in detail below.

3.1. Vitamin Intake and Supplementation Practices Among Pregnant Women

During pregnancy, maternal micronutrient requirements increase substantially due to expanding maternal tissues, heightened metabolic demands, placental development and fetal growth. These requirements vary depending on maternal age, body mass index (BMI), parity, and the presence of pre-existing medical conditions [7,31]. Although international recommendations support supplementation to prevent deficiency-related outcomes, evidence from Greece is limited, but suggests substantial variation in both dietary adequacy and supplementation practices.

3.1.1. Folic Acid and Iron

Folic acid and iron supplementation are widely reported among pregnant women in Greece; however, usage patterns often deviate from clinical guidelines. A cross-sectional study of 100 pregnant women across all trimestersfound that 92% used at least one supplement. Nevertheless, a substantial proportion exceeded the dietary reference intakes (DRIs), with 84% surpassing recommendations for calcium, 80% for iron, and 20% for magnesium. Folic acid intake exceeded safe levels in 8% of participants. Although supplementation partially corrected some dietary inadequacies, overall nutrient intake remained suboptimal. Notably, folic acid use declined in the third trimester, and supplementation patterns varied according to parity, dietary quality and educational level [32].

A larger prospective study involving 1279 women with singleton pregnancies from the (Rhea Mother-Child Cohort in Crete, Greece) RHEA cohortinvestigated the association between high-dose folic acid and iron supplementation with pregnancy outcomes. Most women reported using folic acid (87.7%) and iron (85.2%), with 66% adhering to the recommended 5 mg/day folic acid dose. This dosage was associated with significantly reduced risks of preterm birth (−31%), low birth weight (−71%), and small-for-gestational-age neonates (−66%). Doses exceeding 5 mg/day did not confer additional benefit. In contrast, iron supplementation above 100 mg/day was associated with a twofold increased risk of fetal growth restriction (FGR) [33]. These findings support the early initiation of folic acid at clinically recommended levels and underscore the potential adverse effects of excessive iron intake.

3.1.2. Vitamin D

Despite Greece’s favourable geographic location, vitamin D deficiency remains prevalent among pregnant women and their offspring. In a cohort of 129 mother–neonate pairs, 60% of neonates were either vitamin D deficient or insufficient at birth. Neonatal deficiency was associated with elevated parathyroid hormone levels, reduced corrected calcium and reduced limb length—suggestive of impaired skeletal development. Moreover, both maternal deficiency and even modest alcohol consumption were independently associated with increased risk of neonatal vitamin D deficiency [34].

Further evidence from a cross-sectional study of 248 women confirmed high rates of maternal deficiency, with 58% classified as deficient (<20 ng/mL) and 83% as insufficient (<30 ng/mL) at delivery. Daily vitamin D supplementation significantly improved maternal serum concentrations of 25-hydroxyvitamin D [25(OH)D], particularly when combined with regular consumption of vitamin D-rich foods and ≥30 min of daily sun exposure. Regular intake of fatty fish, eggs, and fortified dairy products was associated with higher serum levels. Seasonal variation was also observed, with summer deliveries yielding higher 25(OH)D concentrations [35]).

Sociodemographic and behavioural factors, including primiparity, non-smoking status and greater sun exposure, were positively associated with vitamin D sufficiency. Conversely, participants with poor dietary quality, limited sun exposure, and lack of supplementation exhibited markedly lower serum levels, with 85% remaining deficient [35].

A subsequent seasonal and environmental analysis of the same cohort, demonstrated significant reductions in maternal and neonatal vitamin D status during the cold season (mid-October to March), with maternal levels averaging 16.96 ng/mL and neonatal levels 12.87 ng/mL—both within the deficiency range. In contrast, warm-season levels were significantly higher. Maternal 25(OH)D concentrations strongly predicted neonatal levels, yet prenatal supplementation (400–800 IU/day) only partially mitigated deficiency. Among supplemented mothers, maternal deficiency rates were halved (32% vs. 64%), but neonatal deficiency persisted in 73% of cases [36].

Multivariate analysis identified season, sun exposure, and smoking status as independent predictors of maternal 25(OH)D levels, whereas BMI, socioeconomic status, and physical activity were not significant [36]. These findings underscore the limited efficacy of standard supplementation regimens in overcoming environmental and seasonal constraints and support the need for tailored strategies considering Ultraviolet (UV) exposure and air pollution.

3.1.3. Iodine

Iodine is an essential micronutrient required for the synthesis of thyroid hormones, which play a pivotal role in regulating metabolism, fetal growth and neurodevelopment. During pregnancy, iodine requirements increase substantially due to elevated maternal thyroid hormone production, increased renal iodine clearance and transplacental transfer to the fetus. As a result, pregnant women are particularly vulnerable to iodine insufficiency, even in populations where general iodine status is considered adequate [37].

In Greece, iodine deficiency remains a prevalent concern among pregnant women. In a nationally representative study of 1118 pregnant women across 19 regions of Greece, 61% had urinary iodine concentrations below the World Health Organization (WHO)-recommended threshold of 150 µg/L, with 32% classified as moderately and 7% as severely deficient. Although serum thyroglobulin remained stable, trimester-specific changes were observed in thyroid function; serum Thyroid Stimulating Hormone (TSH) increased and free T4 decreased progressively, suggesting physiological adaptation to marginal iodine deficiency. Urinary iodine concentrations remained consistently low throughout all trimesters, suggesting persistent insufficiency during gestation [38].

Although Greece has adopted iodine fortification of salt as a preventive public health measure, the policy remains voluntary and is therefore not universally implemented [39]. As a result, dietary iodine intake may fall below recommended levels, especially during pregnancy when physiological requirements increase. Supplementation is therefore common, but must be carefully monitored, as excessive iodine intake may lead to thyroid dysfunction or toxicity [40].

3.1.4. Preconception Intake and Overall Micronutrient Adequacy

Habitual micronutrient intake was assessed in a cohort of 1100 pregnant women during the six months preceding conception. The Mean Adequacy Ratio (MAR) was 93% when all nutrients were included. However, it declined to 78% when excluding nutrients consumed in excess (Nutrient Adequacy Ratio, NAR > 1.5).

Key pregnancy-related micronutrients—namely folic acid, iodine, vitamin D and biotin—had the lowest adequacy ratios. Vitamin D (NAR = 0.07) and iodine (NAR = 0.46) were particularly inadequate, falling well below recommended thresholds. Potassium, vitamin B1 and B2 were also frequently inadequate, whereas niacin and vitamin K were often consumed in excess.

Subgroup analyses revealed that women ≤ 35 years had higher micronutrient intake, whereas smokers exhibited elevated intake of vitamin C and B12 but lower overall adequacy. Overweight and obese women had significantly lower intake of calcium, iodine and B-complex vitamins. Although supplementation was not directly assessed, these findings suggest that dietary intake alone was insufficient to meet preconception nutritional requirements. Furthermore, 12.8% of participants exceeded the tolerable upper intake level for magnesium, highlighting potential risks associated with unsupervised supplement use [41].

3.1.5. Predictors of Supplementation

Across the included studies, predictors of supplement use consistently included Greek ethnicity, non-smoking status, higher educational attainment, primiparity, twin pregnancies, low dietary quality and pre-pregnancy underweight or overweight status [32,33]. These findings suggest that supplement use is frequently determined by sociodemographic and obstetric characteristics rather than clinical evaluation of individual nutritional needs.

3.1.6. Synthesis of Findings

Collectively, the evidence demonstrates that while supplementation practices are widespread among pregnant women in Greece, both dietary and supplemental intake often fail to meet international guidelines. Diet alone is inadequate for achieving sufficiency in critical micronutrients. In contrast, excessive intake of certain nutrients, such as iron and magnesium, raises concerns about potential toxicity. Folic acid appears protective when administered at recommended doses, whereas iron and vitamin D demonstrate variable effectiveness depending on dosage, timing, and environmental factors. Iodine deficiency remains a persistent issue, highlighting the need for pregnancy-specific public health strategies.

These findings highlight the need for nationally standardized, evidence-based supplementation protocols that consider seasonal variability, lifestyle factors, and individual risk profiles. Integrating comprehensive, evidence-based antenatal nutritional counselling into routine prenatal care could improve maternal micronutrient status and reduce the risk of both deficiency and overexposure during pregnancy.

Table 1. Summary of key studies and factors analyzed on maternal nutrition and health behaviours in Greece (2010–2025).

Study	Sample/Design	Main Focus	Main Findings	Implications for Practice/Policy
[32]	Cross-sectional, 100 pregnant women	Supplementation practices and dietary adequacy	92% reported supplement use; excess intake common for calcium (84%) and iron (80%); suboptimal folate intake persisted in 8%.	Highlights need for clinical supervision and standardized supplementation guidelines.
[33]	Prospective, 1279 women	Folic acid and iron supplementation and birth outcomes	High adherence to folic acid (87.7%) and iron (85.2%); folic acid 5 mg/day reduced risk of preterm birth by 31%. Excess iron (>100 mg/day) increased growth restriction risk.	Confirms benefits of guideline-level folate; warns against unsupervised high-dose iron use.
[34]	Cross-sectional, 129 mother–infant pairs	Vitamin D status and neonatal outcomes	60% of neonates were vitamin D deficient at birth; deficiency linked to impaired skeletal development.	Supports routine vitamin D assessment and context-specific supplementation.
[35,36]	Cross-sectional, 248 women, multi-seasonal	Seasonal and environmental variation in vitamin D	58% of mothers deficient (<20 ng/mL); higher levels in summer deliveries; supplementation (400–800 IU/day) halved maternal deficiency but not neonatal.	Emphasizes need for adjusted vitamin D dosing by season and exposure.
[38]	National sample, 1118 pregnant women, 19 regions	Iodine deficiency and thyroid function	61% below WHO iodine threshold (150 µg/L); TSH increased across trimesters, indicating thyroid stress.	Calls for review of iodized salt policy and pregnancy-specific iodine programmes.
[41]	Cross-sectional, 1100 women	Preconception micronutrient adequacy	Vitamin D and iodine most inadequate (NAR 0.07 and 0.46); 12.8% exceeded magnesium upper limit.	Underlines insufficient preconception counselling and supplement oversight.
[42]	Prospective, 400 women	Tobacco, caffeine, and alcohol use during pregnancy/lactation	Smoking decreased from 17.6% in pregnancy to 5.6% during lactation, rebounding to 16.9% post-weaning; caffeine use >80% across perinatal period.	Demonstrates persistent behavioural risks and weak cessation support systems.
[43]	Implementation study, primary care network	Midwife-led cessation counselling	Training improved provider competence; pilot sites achieved measurable smoking reduction.	Highlights scalable community-based models for behavioural change.
[44]	Cohort validation (PPAQ-Greek) of 1058 women	Physical activity validation and levels	Median total PA 142 MET-h/week; only 14.8% met WHO PA guidelines.	Indicates urgent need for structured antenatal PA counselling.

Abbreviations: PA, physical activity; MET-h, metabolic equivalent task-hours; NAR, nutrient adequacy ratio; WHO, World Health Organization; IU, international units; TSH, thyroid-stimulating hormone.

presents a detailed overview of the principal Greek studies conducted between 2010 and 2025, summarizing sample characteristics, research focus, key findings, and practice implications. This synthesis serves to contextualize the subsequent sections addressing behavioural exposures and physical activity during pregnancy.

3.2. Caffeine, Tobacco and Alcohol Use Among Pregnant Women

Maternal lifestyle behaviours during pregnancy and lactation, including caffeine intake, tobacco use and alcohol consumption, significantly influence perinatal and long-term child health outcomes. Although global public health guidelines recommend minimizing or eliminating exposure to these substances, recent evidence from Greece indicates that such behaviours remain prevalent during the perinatal period, often surpassing recommended safety thresholds.

3.2.1. Caffeine

Caffeine consumption remains widespread among pregnant and lactating women in Greece, despite international recommendations to limit intake due to associations with miscarriage, FGR and neurodevelopmental delay [45]. The American Pregnancy Association recommends a maximum intake of 200 mg/day.

Findings from two prospective cohort studies conducted across multiple maternity hospitals in Greece, indicate that caffeine use decreased significantly during pregnancy—from 96.3% pre-pregnancy to 84.7% during gestation. Consumption remained common in the early postpartum period, with 65.8% of mothers reporting intake on the fourth day postpartum, increasing to 71% at one month and 64.7% at three months, before declining to 54.2% by six months [46].

Although overall consumption declined compared to preconception, a substantial proportion of women continued caffeine consumption throughout the perinatal period. Importantly, caffeine intake during lactation was positively associated with breastfeeding duration, and higher pre-pregnancy consumption predicted longer continuation of breastfeeding. These associations may reflect broader behavioural or lifestyle patterns, rather than a direct causal effect. Nonetheless, the persistence of caffeine consumption—albeit often within recommended thresholds—suggests suboptimal awareness or inconsistent counselling regarding intake guidelines during pregnancy and lactation [42].

Therefore, although evidence from pregnant women in Greece indicates a reduction in consumption during pregnancy, awareness of and compliance with these guidelines remain incomplete.

3.2.2. Tobacco Use

Maternal smoking in Greece remains a significant public health concern. Prevalence rates among pregnant women vary widely, ranging from 12.4% to 48% [42,47,48,49,50,51], one of the highest in Europe. This finding indicates limited effectiveness of smoking cessation interventions, likely attributable to the continued social normalization of smoking and gaps in cessation support frameworks.

Smoking during pregnancy is associated with adverse outcomes, including increased risk of intrauterine growth restriction, preterm birth, and sudden infant death syndrome (SIDS) [52]. Strikingly, 20% of pregnant women reported using e-cigarettes during pregnancy, and 10.5% believed secondhand smoke was not harmful to the fetus, reflecting significant misinformation or ambivalence regarding smoking risks [47]. Psycho-social predictors of continued smoking included nicotine dependence, depressive symptoms, low social support, multiparity and lower educational attainment [51].

Postpartum tobacco use also remains prevalent. One study reported that smoking rates decreased further during lactation (5.6%) but rose again to 16.9% following cessation of breastfeeding. Smoking during pregnancy was also associated with shorter breastfeeding duration and increased likelihood of early weaning [42]. These patterns point to limited access to cessation support, as only a small proportion of women reported plans to consult smoking cessation services.

3.2.3. Alcohol Consumption

Alcohol consumption during pregnancy in Greece appears to be declining but is still present. Earlier studies reported prevalence rates of 9.3–11% [47,53], whereas more recent data indicated a lower rate of 5.7% during pregnancy [42]. This trend suggests improving awareness and adherence to international guidelines, which emphasize that no level of alcohol intake is considered safe during pregnancy due to risks of fetal alcohol spectrum disorders (FASD), neurodevelopmental impairment, and other adverse outcomes [54].

Alcohol use continued into the postpartum period among a minority of women. A prevalence of 5.5% alcohol use during lactation has been reported, which, although lower than global averages, remains clinically relevant due to the potential for ethanol transfer into breast milk and its implications for infant sleep, growth, and neurodevelopment. Interestingly, alcohol consumption during lactation was associated with longer breastfeeding duration, though causality remains unclear and may reflect broader socio-behavioural patterns [42].

Together, the findings suggest that while some improvements in maternal substance use have occurred—particularly regarding alcohol—tobacco and caffeine use remain widespread. The persistence of these behaviours highlights gaps in public health messaging, clinical screening, and the provision of targeted behavioural support during the perinatal period. Interventions to improve maternal awareness and adherence to international guidelines are urgently needed to reduce the risks associated with these exposures.

3.3. Physical Activity

Regular physical activity (PA) during pregnancy is widely endorsed by international organizations for its role in promoting maternal health, reducing gestational complications, and improving neonatal outcomes. The ACOG and WHO recommend that pregnant women engage in at least 150 min of moderate-intensity aerobic activity per week, barring obstetric or medical contraindications [55]. Despite these guidelines, evidence from Greece indicates consistently suboptimal PA levels among pregnant women, with multiple barriers contributing to underachievement of recommendations.

A large-scale, prospective, multi-regional study validated the Greek version of the Pregnancy Physical Activity Questionnaire (PPAQ) and assessed physical activity levels in 1058 pregnant women. The PPAQ demonstrated strong internal consistency and external validity when compared with smartwatch-derived step counts and standardized Metabolic Equivalent of Task (MET) data. The median total PA was 142.1 MET-hours/week, yet only 14.8% of participants met international recommendations. Women with higher educational attainment were significantly more likely to engage in structured exercise and had higher overall PA levels [44]. The study further observed that PA increased modestly with advancing gestational age across several domains, including exercise, occupational and transportation activities, with statistically significant differences observed between trimesters. Household and caregiving activities remained the dominant form of PA across all trimesters. Importantly, moderate-to-vigorous intensity PA also increased over time, albeit modestly, indicating a modest behavioural shift over the course of gestation.

In contrast, a smaller-scale observational study of 193 women found that PA levels declined significantly during pregnancy compared to pre-pregnancy levels, particularly in transportation and recreational exercise domains. Among the women surveyed, only 18.1% reported regular exercise during pregnancy, while 37.3% engaged in minimal activity and 11.9% were completely inactive. The only activity that increased during pregnancy was leisure walking, typically slow-paced. The study also identified a notable gap in professional guidance, with just 32.1% of participants receiving encouragement from their obstetrician to exercise, pointing to missed opportunities in clinical care to promote PA adherence [56].

Moreover, among 49 pregnant women assessed using PPAQ, third-trimester women were significantly more sedentary than those in earlier trimesters. Further analyses indicated that lower socioeconomic status, along with later gestational stage and elevated BMI, were significant negative predictors of PA engagement. These findings emphasize the cumulative effects of physiological burden and socioeconomic stressors on PA behaviour as pregnancy progresses [57].

Collectively, these studies reveal a consistent underperformance in PA engagement among pregnant women in Greece, with fewer than one in five achieving recommended levels. Although some increase in moderate-to-vigorous intensity PA is observed with gestational advancement, most physical activity remains unstructured and low-intensity, dominated by domestic tasks. Educational attainment and supportive clinical environments appear to facilitate PA engagement, while higher BMI, socioeconomic vulnerability, and limited professional counselling contribute to physical inactivity.

The findings across micronutrient intake, lifestyle behaviours, and physical activity indicate a pattern of partial adherence to maternal health recommendations, shaped by multiple interacting determinants. These are summarized in Figure 1, which presents a conceptual framework highlighting the multilevel drivers of maternal health behaviours and outcomes in Greece.

4. Discussion

The present review highlights persistent nutritional inadequacies and suboptimal health behaviours among pregnant women in Greece, despite global consensus on the importance of prenatal preventive care. These findings are discussed in the context of physiological, behavioural and structural determinants, compared with international evidence, and used to identify priority areas for intervention and future research.

4.1. Interpretation of Micronutrient Findings

The widespread use of supplements—particularly folic acid and iron—reflects growing awareness of micronutrient importance during pregnancy. Yet, the inconsistencies between supplement use and adherence to recommended dosages underscores a gap between public awareness and evidence-based practice. Similar patterns have been reported across Europe: a multicentre study of 1804 pregnant women in Finland, Italy, Poland, and the United Kingdom found that, while91% of participants used at least one supplement, only 81% were aware of folic acid recommendations and just 58% knew the correct guidance for vitamin D. Nearly one-fifth (19%) of users exceeded the safe upper intake limit for at least one nutrient, despite reporting confidence in their knowledge of appropriate supplement types and dosages [58]. These findings mirror the Greek context, where supplement use is common but often unsupervised, leading to both nutrient deficiencies and potential excesses.

Vitamin D and iodine deficiencies remain particularly concerning in Greece despite abundant sunlight and widespread iodized salt availability. This paradox likely reflects cultural and lifestyle shifts—such as reduced outdoor exposure, air pollution, and lower use of fortified foods—that limit effective vitamin D synthesis and iodine intake. Similar patterns have been observed in Mediterranean cohorts highlighting that latitude alone is insufficient to ensure adequate vitamin D status [59]. Moreover, inadequate preconception micronutrient status, particularly for vitamin D and iodine, underscores the need for nutritional counselling to start earlier, ideally during pre-pregnancy health visits [60].

The variation in supplementation patterns by education, parity and socioeconomic status in Greece highlights the influence of broader social determinants on maternal health behaviours. Evidence from the Polish Mother and Child Cohort (REPRO_PL) supports this, showing that women with higher education levels, older age, and greater socioeconomic status were significantly more likely to adopt a healthier dietary pattern—rich in fruits, vegetables, legumes, whole grains and lean proteins—compared to those adhering to a more “Western” diet high in processed foods and refined grains [61]. These disparities underscore the need for equity-driven, context-sensitive strategies in maternal health promotion, rather than generic national campaigns.

4.2. Lifestyle Behaviours and Substance Use

The persistence of caffeine and tobacco use during pregnancy and lactation reflects behavioural inertia and gaps in public health messaging. While caffeine intake among Greek women often declines during pregnancy, continued use by over half of women postpartum suggests limited awareness of potential risks. High caffeine intake has been associated in some studies with low birth weight, preterm birth and childhood overweight. Emerging evidence also points to possible effects on fetal neurodevelopment and long-term metabolic health, although findings remain mixed due to differences in study design and self-reported intake [62]. These uncertainties underscore the need for clearer guidance and more targeted education during pregnancy and the postpartum period.

Tobacco use, meanwhile, remains a critical challenge. The prevalence of smoking during pregnancy in Greece—among the highest in Europe—reflects systemic shortcomings in cessation counselling and policy implementation. Evidence from the TITAN Greece and Cyprus primary care network demonstrates that midwife- and nurse-led interventions can substantially reduce smoking prevalence when implemented at scale [43]. In Greece, the lack of formal cessation training among midwives and inconsistent use of behavioural screening tools may be primary barriers to progress.

The declining trend in alcohol consumption during pregnancy in Greece is a positive development; however, even low levels of prenatal alcohol exposure are associated with the risk of fetal alcohol spectrum disorders and long-term neurocognitive impairments [63]. Evidence indicates that no safe threshold of alcohol consumption has been established during pregnancy, and minimal intake may still disrupt fetal brain development [64]. Some studies report longer breastfeeding durations among women who consume alcohol occasionally, but this likely reflects confounding lifestyle or sociocultural variables—such as higher maternal education or planned pregnancies—rather than any protective effect of alcohol itself [18]. Clarifying such nuances is critical for developing accurate, culturally sensitive public health messages aimed at preventing alcohol-related harm.

4.3. Physical Activity and Sedentary Behaviour

Physical inactivity during pregnancy, as documented in Greek cohorts, reflects a global public health concern with multifactorial roots. Common barriers include physiological fatigue, time constraints and uncertainty about the safety of prenatal exercise, all of which discourage women from engaging in moderate or vigorous activity. International data confirm the scale of the issue: between 60% and 80% of pregnant women globally do not meet the WHO’s PA guidelines [65]. In Greece, these challenges are further compounded by insufficient clinician engagement, with only one-third of women reporting that they received advice to exercise. These findings highlight the urgent need for proactive, evidence-based counselling to support maternal physical activity during pregnancy.

Even modest increases in PA improve gestational weight gain, insulin sensitivity and maternal mental health, clinical inertia represents a missed opportunity for low-cost, high-impact intervention. Trials in the UK and Nordic countries have demonstrated that integrating brief, structured exercise counselling into routine antenatal care—supplemented by written activity plans and digital tools—can significantly improve adherence to PA guidelines during pregnancy [66,67]. In Greece, the predominance of household chores in women’s PA profiles suggests a common misconception that routine domestic tasks equate to sufficient exercise. While these activities contribute to daily energy expenditure, they rarely meet the intensity or duration thresholds needed for cardiovascular or metabolic health benefits [68]. Public health campaigns that emphasize the importance of intensity, frequency and safety of prenatal exercise may help address these misunderstandings and promote sustained behaviour change.

4.4. Structural and Systemic Determinants

Beyond individual behaviours, system-level barriers play a significant role in shaping maternal health in Greece. Fragmented prenatal services, limited access to midwifery care, and poor coordination between obstetricians and primary care providers undermine the delivery of consistent, preventive care. The absence of national guidelines for supplementation and screening further contributes to uneven service quality.

Similarly to other Central and Eastern European countries, Greece faces systemic challenges, including inadequate resource allocation, outdated medical training, and gaps in affordability and accessibility of care—issues that are well-documented across the region [69]. The lingering effects of Greece’s economic crisis have exacerbated disparities in maternal healthcare, particularly for low-income and migrant women, who are disproportionately affected by food insecurity, limited access to public services, and an increased reliance on costly private care [28,70].

Addressing these issues requires integrated policy reforms, including nutritional subsidies, community-based midwifery programmes, and culturally sensitive health education to ensure equitable maternal care.

4.5. Integrative Perspective

Taken together, the evidence reveals a pattern of partial adherence to maternal health recommendations in Greece. While many pregnant women demonstrate awareness of recommended practices, systemic and contextual barriers—including fragmented care, limited clinical guidance and uneven service access—impede full implementation. The paradox of widespread supplement use coexisting with persistent micronutrient deficiencies highlights the need for structural, rather than solely behavioural, interventions.

At the core of maternal health disparities lies the intersection of nutrition, behavioural factors and healthcare system organization. Addressing these inequities requires a shift from reactive, medically centred antenatal models toward preventive, community-based frameworks. Strong evidence supports midwifery-led continuity of care, which is associated with improved clinical outcomes, higher maternal satisfaction, and reduced inequalities [71,72]. Implementing such models in Greece will require policy integration, cross-sector collaboration, and ongoing monitoring to ensure context-specific responsiveness and sustainability.

5. Public Health Implications

Maternal nutrition and lifestyle behaviours during pregnancy in Greece reflect fragmented public health strategies, inconsistent provider training, and gaps in patient education. While available research shows high rates of supplement use, they also reveal inconsistent adherence to recommended dosages, poor timing and significant risks of both deficiency and overconsumption [32,33,35,38,41]. Particularly concerning are the suboptimal intakes of folic acid, iodine, vitamin D, and iron—nutrients fundamental to pregnancy outcomes. Despite strong evidence supporting appropriate supplementation, these gaps point to insufficient counselling and the lack of national guidelines tailored to local dietary patterns and seasonal variation [34,36].

Equally critical are maternal lifestyle exposures, especially tobacco, alcohol and caffeine use. Although declining in the past five years—possibly due to COVID-19-related restrictions—substance use remains prevalent. Studies show that up to 17.6% of women continue smoking during pregnancy, and 5.7% consume alcohol while pregnant, with minimal postnatal declines [42,47]. Meanwhile, caffeine use remains widespread, with over 80% of pregnant and lactating women consuming it at some stage during the perinatal period [42,46]. These findings suggest both behavioural persistence and systemic underuse of routine screening practices in antenatal care.

Although global guidelines consistently promote moderate-intensity physical activity throughout pregnancy, the vast majority of Greek pregnant women remain insufficiently active. Less than 15% meet global activity guidelines, with participation in recreational exercise particularly low [44,56]. Cultural norms, limited prenatal counselling, and low clinician engagement (only one-third of women report receiving advice from their obstetrician) contribute to this inactivity [56]. While household and caregiving tasks comprise most reported activity, these may not confer the same cardiovascular or metabolic benefits as structured exercise. Sedentary behaviour increases in later trimesters, with higher BMI and socioeconomic disadvantage further compounding inactivity [44].

These findings reflect broader systemic shortcomings. Antenatal visits in Greece often prioritize obstetric monitoring, with limited integration of lifestyle assessment or behavioural counselling. Structured screening tools for substance use, diet, or physical activity are rarely employed in standard care [73]. Addressing these behavioural risk factors requires active engagement from healthcare providers. Among them, midwives play a pivotal role. A recent review shows that the potential of community-based perinatal midwifery in Greece remains largely untapped, due in part to a lack of policy support, limited interdisciplinary collaboration and variable training standards [73]. In fact, only 32.7% of Greek midwives feel confident in supporting smoking cessation, with 78% lacking formal training. Yet these same midwives express strong willingness to acquire these skills—indicating a missed opportunity to mobilize a workforce already embedded in antenatal care [74].

Together, these data argue for the development of a national maternal health strategy that includes structured supplementation guidelines, routine lifestyle screening and sustained investment in perinatal education and counselling. Midwives should be central to this strategy, with policy efforts directed at enhancing their scope of practice, training and autonomy, as highlighted by previous work [73,74]. Interventions should not only address individual behaviour change but also target systemic barriers, including lack of provider training, inconsistent health messaging and insufficient coordination between levels of care. Without integrated, context-specific action, maternal and neonatal health outcomes in Greece are unlikely to improve equitably or sustainably.

6. Future Research Directions

Future research on maternal nutrition and perinatal health in Greece must move beyond descriptive studies toward mechanistic, integrative and implementation-focused approaches. While the current evidence consistently highlights micronutrient deficiencies and behavioural risks during pregnancy, the underlying biological, environmental and systemic determinants remain underexplored. Interdisciplinary collaboration across nutrition science, obstetrics, public health and health policy is essential to address these gaps.

A key priority is elucidating the biochemical pathways through which deficiencies—particularly of vitamin D, iron, and iodine—contribute to adverse pregnancy outcomes. Despite abundant sunlight and dietary resources in Mediterranean regions, deficiency rates remain high, suggesting complex interactions among genetics, metabolism and environment [75]. Longitudinal cohort studies integrating biomarker profiling (e.g., serum 25(OH)D, ferritin, urinary iodine) with detailed dietary assessment are needed to track seasonal and geographic variation in nutrient status. This work should also investigate gene–nutrient interactions, focusing on polymorphisms in MTHFR, VDR, and HFE, which modulate folate and iron metabolism and influence supplementation efficacy [76]. Genomic and metabolomic analysis of placental tissue may further reveal how maternal nutrition impacts oxidative stress, immune regulation and fetal development.

Equally important is implementation science research to translate evidence into antenatal care. Although public health messaging in Greece emphasizes healthy behaviours, substance use and physical inactivity remain prevalent during pregnancy. Mixed-methods studies are needed to examine sociocultural, psychological, and economic drivers, and to evaluate tailored interventions—particularly midwife-led and community-based models, such as those piloted in the TITAN network for tobacco cessation [43]. Implementation frameworks can support the adaptation and scale-up of such strategies within the Greek primary care system.

Professional training and knowledge translation also represent critical frontiers. Studies should assess how continuing education, digital tools and structured counselling protocols influence clinician adherence to nutrition and activity guidelines. Evidence from Northern European trials shows that brief, structured antenatal counselling can significantly improve maternal behaviours, including PA and dietary compliance [77,78]. Testing similar interventions in Greek healthcare settings will help determine their cultural acceptability and feasibility.

At the systems level, there is a pressing need for a national maternal health registry in Greece to enable systematic monitoring of supplement use, dietary trends, and perinatal outcomes. The Global Network’s Maternal Newborn Health Registry (MNHR) offers a proven model, demonstrating how community-based, longitudinal data can inform maternal health policy even in settings with weak health information systems [79]. To ensure equity, such a registry must also capture social determinants—including income, education, and geographic access—allowing for targeted interventions and the reduction in health disparities. Evidence from Germany and New Zealand demonstrates how centralized, register-based maternal health data can effectively support policy development and equity planning [80]. Beyond surveillance, this infrastructure would facilitate evidence-based policymaking and quality improvement in maternal care.

Finally, climate-related stressors such as heat exposure and air pollution should be investigated as emerging modifiers of maternal metabolism, vitamin D synthesis and oxidative stress, particularly in urban Mediterranean settings. Interdisciplinary research at the interface of obstetrics, nutrition and environmental science will be crucial for designing seasonal supplementation policies and climate-resilient public health interventions [81].

In summary, the next decade of maternal health research in Greece must shift from fragmented, small-scale studies toward a coordinated, multi-level research agenda that bridges biomedical science, behavioural insights and policy evaluation. Investment in infrastructure, training and digital monitoring tools will be key to developing a cohesive, data-driven strategy.

7. Conclusions

The present review highlights significant gaps in maternal nutrition and health-related behaviours during pregnancy in Greece, despite international guidelines and the priorities outlined in the European Union’s maternal health strategy [82]. While supplement use is widespread, adherence to evidence-based dosing remains inconsistent, and dietary intake alone is frequently inadequate. Concurrently, substance use such as tobacco and caffeine remains common, and most women do not meet recommended levels of physical activity.

Collectively, these findings underscore inconsistencies in the delivery of antenatal preventive care, including gaps in screening, counselling and supplementation guidance. Addressing these gaps requires coordinated, culturally sensitive interventions that incorporate standardized guidelines, systematic screening and targeted training of healthcare professionals. A robust investment in antenatal prevention—centred on nutrition, behaviour change, and midwifery empowerment—is essential to improving perinatal outcomes and achieving alignment with global maternal health standards.