As a social worker who has worked in the area of child welfare and cofounded Coalition for Alcohol & Drug Free Pregnancies (CADFP) in Santa Clara County, CA, I have been dismayed by the popular press articles, including a recent one on the Huffington Post that minimize the need for alcohol abstinence during pregnancy.
Too often, I have seen the results of substance-exposed babies, and have been told by women that their Obstetrician or Primary Care Physician told them, "You can drink ... as long as you are not one of those binge drinkers," giving women a license to drink a glass or more per day because the doctor didn't think that level of alcohol was a big deal. Some media writers, or readers, have taken up the cry against what they see as repressive government or "judgmental" health experts who promote abstinence during pregnancy (1). In a reversal of the usual attitude toward substance use in pregnancy, encouraging women to drink "occasionally," (whatever that means), is seen by these individuals as a freedom issue, or a necessity for stress reduction, rather than a risk factor.(2) This is a confusion of politics with medical science. The real effect of prenatal alcohol use on babies can be life-long, irreparable, and terribly costly.
The effects of prenatal alcohol exposure can lead to physical and mental birth defects that range from mild to severe and is known as Fetal Alcohol Spectrum Disorders (FASD). Fetal Alcohol Syndrome (FAS) is the most severe constellation and is one of the most common known causes of mental retardation. Babies with FAS are abnormally small at birth and usually do not catch up on growth as they get older. They have characteristic facial features, including small eyes, a thin upper lip and smooth skin in place of the normal groove between the nose and upper lip. Their organs, especially the heart, may not form properly. Many babies with FAS also have a brain that is small and abnormally formed and have some degree of mental disability. Many have poor coordination, a short attention span and emotional and behavioral problems. In addition, it is estimated that for every child born with FAS, three additional children are born who may not have the physical characteristics of FAS but still experience neurobehavioral deficits that affect learning and behavior for the rest of their life.
There is always the question: What amount of alcohol is safe during pregnancy? There are many variables that influence the effects of maternal alcohol use on the fetus, including genetics, metabolism, and environment. It would be unethical to do a controlled research study comparing the birth outcomes for babies of women who don't drink to those who are told to drink a specified amount from occasional to binging. Research has demonstrated that women who do drink during pregnancy generally do not recall accurately the frequency or amount of use.(3) However there are numerous carefully controlled laboratory research studies which show that even the blood alcohol levels that occur with "light drinking" (as well as, of course, moderate to heavy drinking) can interfere with proper development of the fetal brain.(4)
Advising that women should absolutely avoid alcohol early on in pregnancy, when a baby's organs are still growing, appears to ignore, or underplay, the fact that the baby's brain continues to grow throughout pregnancy or that alcohol use can be a reason for miscarriage (5), stillbirth (6), and premature birth (7), a major health risk for babies. Siobhan Dolan, M.D., MPH, Obstetrician/Gynecologist consultant with the March of Dimes stated, "Sometimes women say that my mother drank when she was pregnant with me, or my sister-in-law drank, or it's ok to have a glass of wine here or there. The bottom line is that your baby, the baby's brain and neurological system are developing throughout pregnancy and that alcohol can interfere with that, so ultimately there is no safe amount of alcohol and the best bet is to stay away from alcohol entirely."
FASD occurs worldwide, in every race and ethnic group, and in children from all socioeconomic backgrounds, with the one common denominator being maternal alcohol use during pregnancy. The Huffington Post article mentions that it is very acceptable in Europe to occasionally drink a glass of wine. But research has found that the prevalence rate of FASD among first-grade children in Italy is 3 percent, and similar studies of farm workers in the Western Cape Province of South Africa place the rate at a staggering 8 percent(8). In the United States, FASD prevalence is estimated to be at least 10 per 1,000 live births, or roughly 40,000 newborns per year;(9) a recent study suggests that prevalence in the western world may be closer to 35/1,000 births.(10)
There is an erroneous interpretation by the popular press that recent studies have shown that occasional drinking during pregnancy "might not be so bad." According to a statement released by the Fetal Alcohol Syndrome Disorder (FASD) Study Group of the Research Society on Alcoholism, which includes hundreds of FASD researchers and clinicians, the results from the study by Kelly and colleagues must be interpreted with extreme caution because of several research limitations. One significant limitation is that the apparent difference between the light drinkers, heavy drinkers and abstainers was due to demographics, not drinking. The "light drinking" mothers were more socially and economically advantaged compared to both the heavier drinkers and the women who did not drink during pregnancy. Higher socioeconomic status is generally associated with better nutrition, prenatal care and postnatal caregiving environments. The study also focused only on outcomes for children up to three years of age. Generally, the adverse effects of light to moderate drinking during pregnancy are subtle and may go undetected in young children until they begin school. (See statement)(11)
So what should a physician to do? Since, 2004, the American College of Obstetricians and Gynecologists (ACOG) has called for OB/GYNs to ask all of their patients about alcohol and drug use and to help women get the help they need regarding alcohol and other substance use. ACOG states that alcohol and substance use is considered a medical issue and a physician's responsibility (12). In Santa Clara County, a survey of 400 OB/GYNs (2007) found that while almost 100 percent of respondents ask their pregnant clients about tobacco use, only 11 percent screen for alcohol; 67 percent reported needing assistance with identifying which women are using substances; and only 35 percent knew that there were facilities available. As we continue to provide training and resources to health care professionals in our county, we see that physicians and other health care providers want to know more about the best tools and resources to assist women. Pregnancy is a window of opportunity to address women's health, and the health and future of babies.
Every woman wants to have a healthy baby. According to the March of Dimes, which also advises complete abstinence from alcohol during pregnancy, women seeking pregnancy health advice often say they want to do everything they can to give their babies the best possible start in life. These women willingly give up favorite activities, foods, or alcohol if they perceive any level of threat to the unborn baby. And if something goes wrong, they want to be able to look their children in the eye and assure them that they acted responsibly during pregnancy. That's why so many moms-to-be choose to abstain from all alcohol use. The alcohol use issue is not about shame, politics, or sensationalism. The fact is that there's no known "safe" amount of alcohol use during pregnancy. Please, if you are pregnant, thinking about becoming pregnant, or breast feeding, don't drink. If you drink, don't get pregnant!
3 Feldman, Y., et al. (1989), Determinants of recall and recall bias in studying drug and chemical exposure in pregnancy. Teratology, 40: 37-45. doi: 10.1002/tera.1420400106.
4 Fetal Alcohol Syndrome Disorder (FASD) Study Group, (10/13/2010). Statement on Light Drinking During Pregnancy, http://fasdsg.org/News_Publications.php?topic=5&category=1
5 Strandberg-Larsen, K., et al. Binge Drinking in Pregnancy and Risk of Fetal Death. Obstetrics and Gynecology, volume 111, number 3, March 2008, pages 602-609.
6 Aliyu, M.H., et al. Alcohol Consumption During Pregnancy and the Risk of Early Stillbirth among Singletons. Alcohol, volume 42, August 2008, pages 369-374.
7 Sokol, R.J., et al. Extreme Prematurity: An Alcohol-Related Birth Defect. Alcoholism Clinical and Experimental Research, volume 31, number 6, June 2007, pages 1031-1037.
8 May, PA, et al. (2007) The epidemiology of fetal alcohol syndrome and partial FAS in a South African community.; Drug Alcohol Depend; 2007 May; 88(2-3); 259-271
9 May, P.A., & Gossage, J. P. (2001). Estimating the prevalence of fetal alcohol syndrome: A summary. Alcohol Research and Health, 25, 159-167.
10 May, P.A., et al. (2006). Epidemiology of FASD in a province in Italy: Prevalence and characteristics of children in a random sample of schools. Alcoholism: Clinical and Experimental Research, 30, 1562-1575.
11 Fetal Alcohol Syndrome Disorder (FASD) Study Group, (10/13/2010). Statement on Light Drinking During Pregnancy, http://fasdsg.org/News_Publications.php?topic=5&category=1
12 At-Risk Drinking and Illicit Drug Use: Ethical Issues in Obstetric and Gynecologic Practice. ACOG Committee Opinion No. 422. American College of Obstetricians and Gynecologists. Obstet Gynecol 208; 112:1449-60, Replaces ACOG Opinion No. 294, issued May 2004.
Submitted by: Patti-Ann Bossert, LCSW
Coalition for Alcohol & Drug Free Pregnancies (CADFP)
3190 S. Bascom Ave., Ste. 180
San Jose, CA 95124
Response reviewed by:
National Office of the March of Dimes, White Plains, New York
Institute for Health & Recovery (IHR), Cambridge, MA
Julie Solomon, PhD, J. Solomon Consulting, LLC