Should women abstain from alcohol throughout pregnancy?
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5232 (Published 06 October 2015) Cite this as: BMJ 2015;351:h5232
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While the teratogenicity of alcohol has been well established, evidence of harm attributable to low-level prenatal alcohol exposure is less clear.
Some early human and animal observational studies among small samples report a dose-dependent effect of prenatal alcohol exposure on IQ. Many more recent studies using rigorous methodologies, however, have found an inverted J-shaped relationship between alcohol exposure and IQ. That is, children exposed to low levels of alcohol show higher IQ scores than children not exposed to any alcohol, and those exposed to higher amounts. Large-scale prospective longitudinal studies including the Avon Longitudinal Study of Parents and Children and the Millennium Cohort study have shown this pattern.
Contrary to what has been reported by Mary Mather and Kate Wiles in this article, the 2014 meta-analysis referred to actually did not show any adverse effects of low level alcohol exposure on childhood behaviour cognition. In fact, a small yet significant ‘positive’ effect of low-level prenatal alcohol exposure was apparent, corroborating findings of the aforementioned cohort studies. However, this finding was no longer statistically significant when only studies controlling for socio-economic factors were included. Nonetheless, to conclude that there is evidence of harm associated with consumption of as little as two glasses of wine during pregnancy would be misrepresenting the best available evidence on the subject.
The premise of the argument in favour of promoting abstinence put forward here, and which forms the basis of public health guidelines advising abstinence, is that there is no evidence for a “safe” threshold of consumption. This is true, and this precautionary principle can be sensibly argued, particularly where the goal is prevention of FASD. In turn, however, there is also no evidence for an “unsafe” threshold of consumption, and this too should be acknowledged. Threat-based messages have been criticised for framing the problem of alcohol use in pregnancy in ways that marginalise the needs of women, particularly those with severe alcohol-related problems. Consideration of the needs of women with an alcohol use disorder who fall pregnant has remarkably often been omitted from discourse regarding alcohol use during pregnancy.
Ensuring that public health messages are consistent with empirical research is an ethical imperative that demonstrates respect for the autonomy of women, and their capacity to make informed choices about behaviour. Maintaining a clear stance advising abstinence from alcohol during pregnancy as the “safest option” in order to reduce the risk of FASD is important. However, without acknowledging that little evidence exists linking low-level prenatal alcohol exposure with actual harms, such messages are likely to be met with scepticism, and perceived to be sensationalised and paternalistic, potentially diminishing their efficacy.
References:
Alati, R., Davey Smith, G., Lewis, S. J., Sayal, K., Draper, E. S., Golding, J., . . . Gray, R. (2013). Effect of prenatal alcohol exposure on childhood academic outcomes: Contrasting maternal and paternal associations in the ALSPAC study. PLoS One, 8(10), e74844.
Alati, R., Macleod, J., Hickman, M., Sayal, K., May, M., Smith, G. D., & Lawlor, D. A. (2008). Intrauterine exposure to alcohol and tobacco use and childhood IQ: Findings from a parental-offspring comparison within the Avon Longitudinal Study of Parents and Children. Pediatric Research, 64(6), 659-666.
Flak, A. L., Su, S., Bertrand, J., Denny, C. H., Kesmodel, U. S., & Cogswell, M. E. (2014). The association of mild, moderate, and binge prenatal alcohol exposure and child neuropsychological outcomes: a meta-analysis. Alcoholism: Clinical and Experimental Research, 38(1), 214-226.
Kelly, Y., Iacovou, M., Quigley, M., Gray, R., Wolke, D., Kelly, J., & Sacker, A. (2013). Light drinking versus abstinence in pregnancy–behavioural and cognitive outcomes in 7‐year‐old children: a longitudinal cohort study. BJOG: An International Journal of Obstetrics & Gynaecology, 120(11), 1340-1347.
Kelly, Y. J., Sacker, A., Gray, R., Kelly, J., Wolke, D., Head, J., & Quigley, M. A. (2012). Light drinking during pregnancy: still no increased risk for socioemotional difficulties or cognitive deficits at 5 years of age? Journal of Epidemiology and Community Health, 66(1), 41-48.
Kelly, Y., Sacker, A., Gray, R., Kelly, J., Wolke, D., & Quigley, M. A. (2009). Light drinking in pregnancy, a risk for behavioural problems and cognitive deficits at 3 years of age? International Journal of Epidemiology, 38(1), 129-140.
Competing interests: No competing interests
Mather and Wiles are to be commended on their article "Should women abstain from alcohol throughout pregnancy?" written with Patrick O'Brien. By striking a note of caution, Mather and Wiles underscore the Hippocratic principle "Primum Non Nocere" (First, do no harm) as a guiding principle for healthcare professionals.
Pregnancy is not a disease; it is a transitory physiologic state created by growth and development of a foetus within its mother's body. It is flawed thinking then, to examine the risk of alcohol consumption as one would document adverse reactions in drug trials. The preciousness of developing life in pregnancy permits only correlation by observational studies; it simply can never be ethically possible to design a randomized controlled trial to test the effect of alcohol in pregnancy in a human model.
Powerful computing power may permit complex simulations in the future on a computer model to determine a "safe dose" of alcohol in pregnancy. Ethics prevent us from conducting randomized controlled trials to examine the effect of alcohol in pregnancy. Until then, causation is difficult to prove; at best science can safely look for correlation. Would Patrick O'Brien refrain from discouraging a pregnant partner to drink alcohol simply because "the evidence against alcohol is lacking"? O''Brien's conclusion that women can be explained the meaning of a unit of alcohol and then be expected to make an informed choice in pregnancy ignores known complications such as Fetal Alcohol Syndrome. In stating so, he clearly overlooks the social and health fallout of binge-drinking that has reached epidemic proportions among British youth. Or has the thalidomide tragedy faded from our collective consciousness? Discussing alcohol consumption with a pregnant patient is not the time for ambiguity. Isn't it better to err on the side of safety for the sake of future generations?
In poor and developing nations such as India, societies traditionally give pregnant women the best of nutrition and care. This protective approach may stem from poor primary health care services. In the West, it is intriguing that pregnant, educated mothers would wilfully consider imbibing alcohol with a fetus growing within them. Is this an arrogance bred by ready access to free and quality healthcare services, one wonders.
To conclude, a would-be mother would do well to heed Mather. And if the evidence is low, is there no role for common sense? Perhaps one should step back and, for once, look beyond Science toward The Humanities. The study of Medicine is to address disease. Perhaps this is why birth and death in developing nations often happen at home rather than hospital. Pregnancy, the fetus, birth and health are about Life itself. This is best appreciated by a verse from a poem by Kahlil Gibran:
Your children are not your children.
They are the sons and daughters of Life's longing for itself.
They come through you but not from you,
And though they are with you yet they belong not to you.
Competing interests: No competing interests
O’Brien rightly rejects bullying intelligent, autonomous, adults just because they are pregnant.(1) The answer to his question “just how common are fetal alcohol spectrum disorders …?”(1) is that alcohol during pregnancy is the foremost cause of preventable mental impairment in Western countries.(2) Moreover, as too few clinicians diagnose prenatal exposure to alcohol at birth, it then becomes too late to offer secondary prevention and treat efficiently when school teachers observe learning difficulties or violent behaviour.
O’Brien recognises medical professionals’ duty to respect patients’ rights (1), but misses the deliberate confusion of many people by the alcohol industry. Alcohol is one of the most significant ‘fast moving consumer goods’ marketed today. Fraudulent scientific publications (3) plus more than £800 million spent annually in the UK on advertising alcohol (4) successfully promote addictive carcinogens and teratogens as a healthy lifestyle choice.
Drinking alcohol is a high risk behaviour. Not a single guideline recommends drinking alcohol. If someone drinks alcohol, all guidelines recommend moderation. The American College of Cardiology quotes Saint Augustine’s wisdom, that “complete abstinence is easier than perfect moderation”.(5) The only people who appear to expect moderate use of an addictive substance are those who support the failed “Responsibility Deal”.(6)
Good advice should be non-stigmatising. It is not reasonable to ask pregnant women to be superhuman, when that standard is not the social norm. We are all members of communities and populations that are drinking more. A kind, child-friendly society might be one in which we all cut our drinking in order to help avoid fetal alcohol syndrome; one that offered effective interventions, rather than just pointing the usual finger of blame. Instead of demonising vulnerable women who can’t stop their problem drinking, what about the government stepping up to the public health challenge?
1 Mather M, Wiles K, O’Brien P. Should women abstain from alcohol throughout pregnancy? BMJ 2015;351:h5232.
2 Braillon A, Dubois G. Alcohol and public health. Lancet. 2005;365:1387.
3 Roehr B. Cardiovascular researcher fabricated data in studies of red wine. BMJ 2012; 344: e406.
4 Institute of Alcohol Studies. Marketing and alcohol. Factsheet. May 2013. Available at http://www.ias.org.uk/uploads/pdf/Factsheets/Marketing%20and%20alcohol%2... . Accessed 10 Oct 2015
5 American College of Cardiology. Available at https://www.acc.org/latest-in-cardiology/articles/2015/01/05/13/06/alcoh.... Accessed 10 Oct 2015
6 Limb M. Public health body quits responsibility deal over government's failure to act on tobacco and alcohol. BMJ. 2013;347:f4590.
Competing interests: No competing interests
Whichever side is right, there is a consequence to be avoided. If a baby is born with a developmental problem (not one that is obviously FAS), should the mother be asked if she drank during pregnancy? If the answer is yes, and she did drink alcohol, she will carry a burden of guilt for the rest of her life, possibly on no real evidence, and this may profoundly affect her relationship with her child.
Competing interests: No competing interests
Re: Should women abstain from alcohol throughout pregnancy?
In agreement with the article, lack of evidence is not the same as evidence of absence of risk and, in this case, no evidence of harm does not mean evidence of no harm; subsequently, no amount of alcohol during pregnancy can be considered safe based on research evidence.
However, some aspects are at least as little convincing as the criticized contradictory advice from health agencies. Sometimes less severe disorders of the spectrum can be associated to a distorted functioning in the daily life at less as severe as complete foetal alcohol syndrome (FAS), especially in adopted children who add the deleterious effects of a long stay in foster care centers.
Certainly, the advice about moderate or low alcohol intake in any week of the gestation must be clear and one: we don’t know if this consumption damages the neurodevelopment of the foetus, so any amount of alcohol can be considered secure and we can’t recommend any other advice that complete abstinence. In this sense, we must consider that the main problem about this subject is not the evidence based discourse but the no damage presumption. As health professionals, we must manage the uncertainty and advice from caution, not from presumption, mainly because an affected child could be hardly overcome by parents.
References:
Vall O, Salat-Batlle J, Garcia-Algar O. Alcohol consumption during pregnancy and adverse neurodevelopmental outcomes. J Epidemiol Community Health. 2015;69:927-9.
Garcia-Algar O, Carballo L, Reguart N, Salat-Batlle J. Neurobehavioural Effects of Prenatal Exposure to Alcohol. J Preg Child Health. 2015;2:177.
Competing interests: No competing interests
As the article rightly pointed out, the guidances available on drinking alcohol during pregnancy are at best, confusing and at worst, contradictory.
However, there are clear documented clinical evidences that alcohol, even at low levels, can cause harm to the foetus. Foetal alcohol syndrome disorder is a collection of symptoms where babies born to mothers who drink alcohol at some point of their pregnancy may develop, such as learning or behavioural problems or physical abnormalities. Critics claim that this only happens when the mother binge drinks but studies have shown though low levels of drinking may not cause growth abnormalities, it can affect the behavioural development of a child.
Because drinking alcohol is so ingrained in our culture, critics try to find an acceptable level alcohol drinking so that even pregnant woman are not totally cut off from this socially acceptable activity. But the truth is that no one knows unequivocally what is the safe level of the alcohol that does no harm to the foetus. Do we have a guideline that says to smoking mothers that it is fine to have a few puffs of cigarette a day when pregnant? There would be an outcry! It's unthinkable! Why then do we have guidelines that say it is permissible to drink a small amount during pregnancy, fully aware that alcohol is a well known teratogen?
In this day and age where we talk about picking the best genes for our babies or 'genetically-enhanced babies', shouldn't we first take the natural and ethically acceptable stance of advising mothers to abstain totally from alcohol throughout pregnancy to give our children the best chance of having a healthy normal development? Giving unclear or seemingly contradictory advice only serves to undercut the very purpose of having a guideline.
References:
McHugh, RK; Wigderson, S; Greenfield, SF (June 2014). "Epidemiology of substance use in reproductive-age women.". Obstetrics and gynecology clinics of North America 41 (2): 177–89.
Prenatal alcohol exposure and childhood behavior at age 6 to 7 years: I. dose-response effect. Sood B, Delaney-Black V, Covington C, Nordstrom-Klee B, Ager J, Templin T, Janisse J, Martier S, Sokol RJ. Pediatrics. 2001 Aug; 108(2):E34.
Competing interests: No competing interests
Women should not go to the movies during pregnancy.
Going to the movies a few times during pregnancy may seem harmless. But it involves spending time in traffic to get there. The serious harms of spending time in traffic is well documented, also for fetuses, and there is no safe lower limit of exposure. While there, to my knowledge, is no direct evidence that the small amount of exposure to trafic on the way to the movies is harmful to pregnant women or fetuses, absence of evidence is not evidence of absence, and there is plenty of indirect evidence, in particular from members of the opposite sex in the same age range as the soon-to-be mother. As going to the movies is not a necessary activity, we need to develop guidelines explaining the risks of moviegoing to pregnant women and advise strongly against any such activity. Even a very small risk is not worth taking when the circumstances are that the activity is not absolutely necessary, Think of the children!
What naysayers to advising clearly against moviegoing for pregnant women fail to recognise is that the ONLY concern in public health is reducing very small risks ever further. Quality of life is of no concern.
Competing interests: No competing interests