Articles

Alcohol and Pregnancy

We know that drinking alcohol during pregnancy can cause birth defects; the government-mandated warnings on alcoholic beverage labels constantly remind us of that fact. But toxicologists remind us that the poison is in the dose: what is the dose of alcohol that causes birth defects? Heavy drinking can cause fetal alcohol syndrome, but there is no evidence that light to moderate drinking can cause it. Alcohol has been implicated in a number of other adverse effects on pregnancy and on the fetus. We simply don’t know if there is a threshold dose below which alcohol intake is safe, so the default position of most medical authorities has been to advise total abstinence during pregnancy. This is not a truly evidence-based recommendation, but rather an invocation of the precautionary principle. Those advising complete abstinence have been accused of paternalism and bias by wine-lovers and other critics, for instance here and here.

The literature on alcohol and pregnancy is extensive and confusing. It addresses many different endpoints, looking at effects on children and on the pregnancy itself. The studies are inconsistent in how they define “moderate” or “light” drinking, and they rely on self-reports that may not be accurate.

It would be impossible to read and accurately summarize such a large body of literature (over 21,000 hits on PubMed!), but here are a few examples that illustrate the scope, diversity, and conflicting results of these studies:

This study found that total abstinence from alcohol during pregnancy was correlated with an increased risk of stillbirth. Alcohol is known to inhibit uterine contractions and has been used IV in hospitals to stop premature labor.

This systematic review found an association of maternal alcohol intake with acute myelogenous leukemia in children.

This study showed a correlation with placental abruption but not with placenta previa.

This study found no association between maternal drinking and autism in general, but it found that binge drinkers (5 or more drinks on a single occasion) were less likely to have autistic children. They reasonably commented that this association was probably non-causal.

This study found a blunted response to pain in alcohol-exposed neonates.

This study found that “children born to mothers who drank up to 1–2 drinks per week or per occasion during pregnancy were not at increased risk of clinically relevant behavioural difficulties or cognitive deficits compared with children of abstinent mothers.”

A study by Willford, Leech, and Day found that prenatal alcohol exposure equivalent to 3-6 drinks a week correlated with lower IQ scores in African-American children but not in whites. As one commentator points out, the same study showed that maternal consumption of cocaine correlated with increased overall IQ scores in white children: this “suggests that perhaps the standards for confounding factors and statistical significance might have been too low.”

I found several websites that mentioned a study of 33,300 California women but I haven’t succeeded in tracking down the study itself. It reportedly showed that even though 47% drank moderately during their pregnancies, none of their babies met the criteria for Fetal Alcohol Syndrome. The authors of this study reportedly concluded “that alcohol at moderate levels is not a significant cause of malformation in our society and that the position that moderate consumption is dangerous, is completely unjustified.”

When studies have conflicting results, we resort to meta-analyses and systematic reviews to try to make sense of the data.

A meta-analysis by Testa, Quigley and Eiden found a detrimental effect on infant mental development at age 12–13 months, but no effect in younger or older infants. And it found a statistically significant improvement in mental development in children of light drinkers at 18-26 months. It’s hard to interpret what this might mean, if it is not a statistical fluke.

A systematic review by Henderson, Gray and Brocklehurst looked for possible effects of light to moderate drinking on outcomes including miscarriage, stillbirth, intrauterine growth restriction, prematurity, birth weight, small for gestational age at birth and birth defects including fetal alcohol syndrome. They

… found no convincing evidence of adverse effects of prenatal alcohol exposure at low–moderate levels of exposure. However, weaknesses in the evidence preclude the conclusion that drinking at these levels during pregnancy is safe.

There are no studies showing harmful effects from 1–3 drinks a week.

Conclusion: The scientific evidence has not identified a threshold below which alcohol consumption during pregnancy is definitely safe, but neither has it shown any convincing evidence of harm at low levels of intake, and it has not ruled out the possibility that low levels might provide a small benefit.

In the absence of better data, we are left to cope with uncertainty. Individuals will have to make decisions based on their philosophy of risk tolerance and their own personal non-scientific reasons. For me, the unconfirmed possibility of a low level of risk was not enough to outweigh the enjoyment of an occasional glass of wine during my pregnancies.

Posted in: Obstetrics & gynecology

Leave a Comment (60) ↓

60 thoughts on “Alcohol and Pregnancy

  1. windriven says:

    “But toxicologists remind us that the poison is in the dose: what is the dose of alcohol that causes birth defects?”

    One might also suspect a variation in teratogenicity dependent on gestational age at exposure.

  2. Jojo says:

    During my first trimester of pregnancy, I craved red wine. Even when I was too nauseous to want to eat, I wanted red wine. It was very odd, but I never did drink any. My cravings turned to orange juice and donuts in the second trimester, and I did indulge in those cravings. A lot. Too much probably.

    When I was doing all my pregnancy research, I came across pretty much the same idea that you have summarized for us. Some drinking is probably OK, but no one knows just how much is safe. I didn’t mind giving up a few drinks during that time, but I do think women should be informed of the current evidence so they can make their own decisions. A flat out zero alcohol recommendation does not seem to be necessary in this case.

  3. mxh says:

    We apply a better safe than sorry approach to lots of other things when it comes to pregnancy and early childhood (especially drug recommendations), so it’s no surprise that the same approach is made towards drinking. I think for all these cases, it would be fine if physicians continue recommending no drinking, but should let their patients know that there isn’t much evidence for it.

  4. Ian says:

    Doesn’t science have anything to say about alcohol and brain development at a more basic level? This is the SBM site not EBM. :D

  5. Ian says:

    Ok just to add to that thought: given that with fetal development we are worried about the “quality” of the baby, not just its health it would seem to be very difficult to judge alcohol passed on the sort of research summarized above. IQ is just not a good measurement.

    But I’m guessing the sort of research summarized above isn’t the only tool science has. We can also think about things at a more fundamental level.

  6. lhaber says:

    One of the reasons that the studies are inconclusive is that alcohol dehydrogenase induction capacity varies in individuals and by ethnicity. Lower levels mean less ability to process alcohol, and therefore more toxicity, to both mom and fetus.

  7. Kylara says:

    Jojo, it’s not unusual in France for a small glass of red wine to be prescribed for morning sickness — I think the tannins are supposed to help? But I craved red wine too when my morning sickness was really bad.

    I remember reading about a (preliminary?) study, rather a while ago, examining alcohol in pregnancy as it correlated with nutrition — the two ideas it was investigated, IIRC, were that a) fetal alcohol syndrome appeared to be more common in poorer countries than richer ones at the same level of alcohol intake and b) people who drink a lot are often not getting adequate nutrition (which you may not particularly notice when not pregnant but could have serious consequences in pregnancy). The conjecture was basically that one reason for (a) might be superior nutrition and widely-available prenatal vitamins in wealthier countries. There were considerably confounding factors the investigators were trying to sort out, but I thought it was an interesting idea.

    On a slightly related note, back in the late 40s and early 50s, when my grandma was having babies, she was having these ginormous nearly 9 pounders coming off rationing when everyone else around her was having scrawny little babies suffering the effects of limited maternal nutrition. My grandma was a small woman with a fairly narrow pelvis and was just having horrific labors and deliveries and finally asked her doctor if there was anything she could do to have smaller babies. His medical recommendation was, “Start smoking.” !!!!!!! (She didn’t.) Although I suppose his recommendation was technically an evidence-based solution to the “problem.” Oy.

  8. Draal says:

    But toxicologists remind us that the poison is in the dose: what is the dose of alcohol that causes birth defects?

    Should the same argument be made for other drugs like heroin, cocaine, smoking, ect. (ignoring any illegal status of the drug for the time being)? Or am I asking the wrong question?

  9. windriven says:

    @ Ian

    “IQ is just not a good measurement.”

    Why not? What would you propose as a better measure?

  10. Harriet Hall says:

    Kylara,

    Re your grandmother’s story: I read that coffee is discouraged during pregnancy because it causes smaller babies. I drank coffee throughout and had 8 and 9 pound babies. I’ve always wondered what they would have weighed if I had avoided coffee. :-)

  11. moderation says:

    @ Harriet Hall:

    If the range of data that you reviewed was about a drug with almost no benefit, I have no doubt your final comment (“unconfirmed possibility of a low level of risk was not enough to outweigh the enjoyment of an occasional glass of wine during my pregnancies”) would have been different. If you could say that one drink a day poses no significant risk to the fetus or if alcohol consumption provided a significant benefit – I could see there being more discussion about this.

    There is also a missing piece of logic to your discussion re: autonomy. This choice has a potential effect on not just the imbiber, but also the fetus – and while I unabashedly support a woman’s right to choose – I don’t believe that once a decision to carry a pregnancy to term she has been made, an individual has a right to expose the fetus to whatever risk they would deem “reasonable” – experimental drug tester, boxing, professional roller coaster rider :-)

    The decision to recommend abstinence is similar to the decision to recommend that OTC cold medicines be pulled for the under 5 age group. The benefits are so minimal that even small risks preclude recommending usage.

  12. superdave says:

    My reading of this (I am a single young adult male, so take this with a grain of salt) is that you should avoid alcohol but not freak out about it. I can imagine there are some hypochondriac pregnant women out there who would just be scared to death if they accidentally had some alcohol.

  13. moderation – “The decision to recommend abstinence is similar to the decision to recommend that OTC cold medicines be pulled for the under 5 age group. The benefits are so minimal that even small risks preclude recommending usage.”

    My understanding from our pediatrician is that OTC cold medicines have directly contributed to the deaths of small children at recommended doses (it is rare) AND they have no proven benefit in small children.

    Unless there are proven deaths associated with occasional light alcohol consumption, I don’t think the OTC cold medicine/alcohol consumption analogy is a good parallel.

    I won’t weigh in on the alcohol guidelines. Never been pregnant. My friends all stopped drinking and never complained about it. MY Sister had an occasional wine sprintzer and resented the flake she got.

    The main problems I’ve heard is not being able to take the OTC pain med or allergy med of preference. Allergy season while pregnant without the best medications seems quite miserable. I believe the OTC guidelines are good, but what a drag.

  14. Angora Rabbit says:

    The problem with saying that occasional drinking in pregnancy is safe is multi-fold. There are known modifiers of risk such as blood alcohol level achieved (both peak and area under the curve), genetics (rate of alcohol metabolism), level of consumption, frequency of consumption. Maternal nutritional status is starting to be appreciated as a player. Women do not know what ADH, AlDH or 2E1 alleles they have inherited, and they especially don’t know which ones the fetus has inherited.

    Alcohol freely crosses the placenta. The embryo/fetus slowly metabolises ethanol. Fetal ethanol levels are about two-thirds of maternal blood levels. But ethanol also enters the amniotic fluid, and when it does the ethanol is persistent, such that the fetus receives longer exposure than does the mother.

    Finally, an non-alcoholic woman may truly have only a few sips or half a glass. But the alcoholic hears this “safe” message and uses it as a rationale for abuse. She has a daily drink (which is associated with poorer gestational outcomes) or worse, saves the alcohol for binge drinking on the weekend.

    My research area is fetal alcohol syndrome. Thus my name is out there on the internet, and I routinely get phone calls or emails from women who wonder about risk when they’ve had only one drink. With additional conversation this often turns into several drinks per sitting, and not one dinner party but every weekend. And then she has a big problem.

    But I also get calls from women who are genuinely non-drinkers, like Dr. Hall’s example, and are concerned. I do tell them that there is unlikely to be damage. I also point out that the fetus / embryo has a tremendous capacity to repair damage. I suggest that the woman stops worrying about that occasion (stress is a risk factor for adverse pregnancy outcome), but that she should cease drinking until they are finished nursing. This is because the woman does not know what other modifying risk factors she and the fetus have, and so she is essentially playing Russian roulette with the fetus if she continues to drink.

    Dr. Hall, please see a very good discussion of moderate drinking and pregnancy at this link. The article was written for the press in response to the 2008 publication by Kelly. The review is short but cites a few of the many references out there about the risk of moderate drinking in pregnancy. Apologies for the review’s appearance as the site is under construction.

    http://fasdsg.org/News_Publications.php?topic=1&category=1

  15. moderation on women’s rights:
    “I don’t believe that once a decision to carry a pregnancy to term she has been made, an individual has a right to expose the fetus to whatever risk they would deem “reasonable” – experimental drug tester, boxing, professional roller coaster rider.”

    You mean you believe pregnant women will be (or should be) arrested and imprisoned for boxing? Please explain why you think this is a good thing.

  16. windriven

    “@ Ian

    “IQ is just not a good measurement.”

    Why not? What would you propose as a better measure?”

    I thought that IQ would not be a good measure because there is actually a very wide range of “normal” and it’s quite hard to control for confounding factors. Or, as one of my pediatricians told us for a non-alcohol related exposure “There’s no way to know what the cognitive function would have been without this exposure”

    I believe when you have a direct tie to lower than normal cognitive fuction and/or delayed developmental outcomes, it’s easier to make the connection. The examples would be lead poisoning and/or FAS for alcohol consumption.

    So I believe it’s hard to make recommendations to optimize and easier to make recommendations that avoid an obvious deficit.

    But I’m not a doctor or scientist. I could be wrong there.

  17. Dawn says:

    @Ailison Cummins: like you, I found that comment to be rather off. While not a professional, I rode roller coasters while pregnant until my OB recommended I stop for the safety of both fetus and me – he was concerned that the safety harness might injure one or both of us.

    (OTOH, he also recommended 1 glass of wine at dinnertime (to last through the evening) if my false labor contractions were too severe, as long as I didn’t exceed 3 in a week. (He also pointed out that, medico-legally, he couldn’t say that) I think in the remaining 3 weeks of pregnancy I had a total of 4 glasses of wine. That child just graduated magna cum laude from college so I guess the wine didn’t cause problems! )

    We all know of women who smoked, drank, did some drugs during pregnancy and had fine healthy babies (One of my 1+ppd smokers had 3 babies all 9+ lbs). Those of us in the medical professions have also seen the opposite.

    While “moderation” may have his/her beliefs about a woman’s deeming a risk reasonable, I hope that he/she does not impose those beliefs on others.

  18. James Fox says:

    @ moderation

    This issue pertaining to individual freedoms is confronted daily by child protection agencies dealing with drug abusing pregnant mothers. In my experience and in seeking legal council on many occasions it appears clear a woman is more or less free to ingest, inject, or smoke what ever they want and not be held responsible for the effects on their child criminally. Risk and diminished capacity are different matters and judgments based on these criteria often results in a drug exposed infant being removed from a mother by the courts. And this discussion does not take into account personal ethics and responsibilities.

  19. “While “moderation” may have his/her beliefs about a woman’s deeming a risk reasonable, I hope that he/she does not impose those beliefs on others.”

    Yes, my issue is “where does one draw the line?” Who draws the line for women? My sister worked through most of all her pregnancies. With her first child, she was accidentally exposed to the blood of a person with HepB. Luckily she didn’t contract HepB, but that could have been a risk to her and her child. If she didn’t need her income, would working have been an unreasonable risk? Is driving when you can walk an unreasonable risk?

  20. Dacks says:

    Dr. Hall,
    When I was pregnant, in the 90s, the push was vehemently towards total abstinence, which I followed with a certain degree of reluctance. A huge guilt trip was laid on the pregnant woman who dared to have a glass of wine at Christmas. At least the temporary nature of the injunction made it easier to take.

    I’ve acquiesced in my mind to the abstinence only policy for all these years, but have recently been turning it over in light of a skeptical outlook and wondered whether it was rational or not. Thank you for reviewing this question – it confirms my hunch that the data for very low doses is not conclusive.

    Re coffee: I questioned the medical personnel vigorously during my pregnancies on the risks of coffee, one of my major food groups, and was reassured repeatedly that there was no risk to the fetus from average coffee drinking. Thank heavens I was allowed that vice! And both babies were sickeningly healthy.

  21. hokieian says:

    For some reason, this discussion reminds me of the following picture that was in the Roanoke (Va) Times a few years ago:
    http://images.encyclopediadramatica.com/images/2/22/Pic-roanoke-smoker.jpg

  22. provaxmom says:

    For me, I chose the ‘better safe than sorry’ route, and just chose to abstain. I was actually kind of amazed that on several occurrences, I was confronted with “Oh it’s ok to have 1 drink…” and almost the inference that I’m some sort of prude. “Europeans do it all the time!” I’d hear. Good for them, let them do it.

    I did have my daily morning coffee and also large babies. One was 9.6, what would he have been without it?

    I once had an employee, and she & I were pg at the same time. She smoked her entire pregnancy and always insisted to me that her doctor said it was ok. I only asked her about it once or twice, as she did work for me, so I had to be careful what I said.

    I do have a child with a chromosomal disorder, so for me, my abstinence from just about everything gives me peace of mind. As a mom of course I beat myself up about it occasionally–but I can at least rest at night knowing I didn’t have alcohol, or any drugs, and I ate right, etc etc. So I don’t have to wonder “I wonder if it was the…..”

  23. mr. grieves says:

    I fail to see the problem with the recommendation for abstinence during pregnancy. You have demonstrated that the evidence is inconclusive regarding safe levels of exposure. When the lack of data is coupled with the fact that ethanol has essentially zero therapeutic value for mother or fetus, the recommendation makes perfect sense. This is identical to the evaluation of any other drug for use in pregnancy. In my opinion this post represents a poor application of science-based medicine.

  24. “In the absence of better data, we are left to cope with uncertainty. Individuals will have to make decisions based on their philosophy of risk tolerance and their own personal non-scientific reasons.”

    I think this is a key point. Science can only give us the best possible information about how things are. It can’t tell us what to do because what we do is based as much on what we want, what we believe, and how we feel as it is on how the world actually is. Many medical decisions seem to be mostly decisions about values.

    Personally, I don’t consider the benefit of enjoying a drink or two worth even the tiniest chance of causing lasting harm to a child, so I prefer to follow the precautionary principle is unreasonable in this situation. Of course, I never had to be pregnant, but I did share my wife’s abstinence during her pregnancy, and it wasn’t really a big deal for either of us. Dr. Hall made a different judgement in her own situation, a decision just as reasonable and consistent with the information we have. Decisions made in the face of true uncertainty about the facts must necessarily be decisions based on values and philosophy.

  25. Scott says:

    mr. grieves,

    You should reread the post. You’ll note that there actually is a certain amount of evidence to indicate that there might be some therapeutic value to alcohol.

  26. daedalus2u says:

    It is very difficult to figure out what dose may be harmful by what mechanism(s) when the mehanism(s) for the fundamental effects of alcohol on adults is not understood. It is believed to be due to some disturbance of the lipid membrane, or perhaps some activation of some receptor, but that isn’t really understood.

    The effects are likely not through some “toxicity” effect (i.e. cells being killed or injured). A “toxicity” effect is not necessary for a compound to be a teratogen, even a very severe teratogen (thalidomide for example). If alcohol does disrupt some kind of “signaling”, then even very low doses might have effects. Alcohol is a normal product of the metabolism of some types of things, so the baseline isn’t zero but may be affected by things like diet.

    So many different things are going on during growth, proliferation and differentiation in utero, and these change enormously over time, so alcohol intake at one time may be harmless and at another time harmful.

  27. Angora Rabbit says:

    Some comments:

    Since fetal alcohol syndrome was originally described by a French investigator (and is still pilloried in France because of it), any arguments about safety because Europeans drink are not founded in data.

    Second, arguments that “I drank in pregnancy and my kids are fine” are also faulty for reasons that SBM readers should know. Not only is anecdote not data, but there is no comparison to know what the child might have achieved.

    The “my kids are okay” argument is also invalid because prenatal alcohol exposure has stronger adverse effects on executive function as compared with learning; indeed, there are FAS kids with IQs of 120. IQ is not a good predictor of outcome because so many more neurobehavioral functions are affected by PAE than just cognition.

    For Daedalus2u, we are getting a pretty good handle on the mechanism of alcohol’s action. There’s no receptor, and ethanol instead displaces water from hydrophillic protein pockets to affect protein structure and function. This is best understood for alcohol’s addictive properties, but also appears to extend to its neurodevelopmental effects. Good evidence in the literature shows that ethanol dysregulates cellular signaling pathways governing events including proliferation, migration, axonogenesis, synaptogenesis. The precise target is dictated by timing of exposure and ethanol concentration. And there is a lot of apoptosis stimulated by ethanol, so the claim that ethanol isn’t “toxic” isn’t supported by the data.

    Bottom line is there is no safe period of pregnancy or lactation (indeed early studies indicate that alcohol affects adolescent brain differently from adult brain), it’s just that the precise target and outcome vary.

  28. Ken Hamer says:

    To me the most fascinating thing about these studies is that they needed to be done in the first place. It speaks to a “need” in much of society to consume what is, whatever else it might be, really a narcotic.

    I’m struck by how often alcohol is a requirement (i.e. toasting at a wedding,) a compensation (i.e. free drinks on an airplane to apologize for a late example) or a reward (i.e. a “free beer” for ‘whatever.’) Is there any occasion that doesn’t somehow ‘require’ an alcoholic beverage — be it a business lunch, a fishing trip, or even a religious holiday?

    For all its history, I’m still not sure I understand how a drug became so essential to everyday life.

  29. windriven says:

    @micheleinmichigan

    Yes, I do see that IQ is an imperfect measure. So what would a better measure be? I am hard pressed to think of one that would easily tie to maternal alcohol consumption and fetal outcomes.

    You may recall the furor that surrounded Hernnstein and Murray’s “The Bell Curve.” IQ measures certainly have their fair share of faults. But they remain a statistically relevant predictor.

  30. Charon says:

    @Ken Hamer: right on. It’s truly bizarre. I’ve attended a few seders, and they passed around this bottle of apparently truly awful wine (Manischewitz – ~10% of the population seems to like it) and wanted to make everyone drink. I’m comfortable being very forceful in my refusal to drink, but it is odd having to argue about it. People who wouldn’t dream of touching a drug like marijuana happily consume alcohol in vast quantities – um, yes, it’s a drug too. Because of the age limit on alcohol consumption, it’s often viewed as “childish” to not consume it.

    (Side note: “i.e.” -> “e.g.” throughout your post.)

  31. windriven – “So what would a better measure be?”

    Firstly, I don’t know, there are such a huge number of tests for different attributes. Also, I’m not sure what you are trying to measure; overall health, general cognitive ability, general abilities such as speech, language, fine gross motor control, emotional resilence, social, attention span, learning ability?

    Also, I think age is relevant. It seems that our pediatric neuropsychologist said that is was very difficult to get a good intelligence measure in younger children. I know that our preschool special education program uses the Battelle Developmental Inventory. But having seen him take the test a couple times I can say that the result varies depending upon the personna of the tester.

    I would think that research into possible consequences of consuming alcohol during pregnancy would not be focused on intelligence alone. FAS is a syndrome as the march of dimes says

    “Babies with FAS are abnormally small at birth and usually do not catch up on growth as they get older….Their organs, especially the heart, may not form properly. Many babies with FAS also have a brain that is small and abnormally formed. Most have some degree of mental disability. Many have poor coordination, a short attention span and emotional and behavioral problems. ”
    http://www.marchofdimes.com/professionals/14332_1170.asp#head2

    So medicine agrees, alcohol in larger quantities effects more than cognitive function. The question seems to be the quantities and the approach to take when the research is unclear.

    It’s highly possible that I’m missing your point here. If so, my apologies.

  32. Chris says:

    Charon and Ken, a possible answer to your question: A History of the World in Six Glasses

  33. windriven says:

    @micheleinmichigan

    No, I don’t think you’re missing my point; I’m not sure that I exactly have one. You have hit the nail squarely here:

    “alcohol in larger quantities affects more than cognitive function. The question seems to be the quantities and the approach to take when the research is unclear.”

    Where is the line? Clearly, momma can’t get blind drunk 3 nights out of 7 and have confidence in delivering a healthy baby. But as we start trimming the daily consumption, where is the magic line (or is there one)? It isn’t difficult to see why most physicians simply suggest no alcohol.

  34. Zoe237 says:

    Hmm, guess I’m the only one with a great big ITA. I think people make way too big a deal out of the very occasional drink (as they do with caffeine, also a drug, with no proven harms at very low doses)). My friend’s ob even recently recommended a glass of wine in the last week of her pregnancy to help her relax. :P

    I don’t recall drinking while pregnant, but I’ve certainly had a drink or two while nursing, since i did so for six years (3 kids). I’ve heard that a dark beer can help lactation as well.

  35. SF Mom and Scientist says:

    @provaxmom – I had the same experience. The smell of wine (or of a lot of things, for that matter) made me want to puke when I was pregnant, so this was never an issue for me. I did have a lot of people look down on me for “abstaining”, like it was some kind of choice.

    I wonder about the whole “Europeans drink while pregnant all the time” thing. My friends in France tell me they abstained from drinking while pregnant and that this is the current recommendation. In any case, I have no problem with pregnant women deciding to have a drink now and then.

    My OB told me that over 50% of pregnancies are unplanned. I would imagine a lot of these women drank before they knew they were pregnant, so this information (moderate drinking might not be so awful) might help them out?

  36. Ian says:

    @windrivenon: well IQ isn’t great at measuring the ‘quality’ of a baby. Like the mentioned study that used it was found to have too many confounding factors.

    And there isn’t a better test, that was the point of my comment.

  37. Ian – “quality of the baby”? What does that mean? I have never heard that term when dealing with pediatricians or doctors.

  38. Kylara says:

    You know, Tylenol is allowed pretty much on the theory that “pregnant women have taken it in moderate quantities forever with little problem” even though there are known risks. Yet when people say, “Pregnant women have consumed alcohol in moderate quantities forever with little problem,” that is somehow a different thing to say.

    And as for the, “Why can’t you just abstain?” people, take a look some time at the lists of things you’re meant to abstain from, which are HUGELY VARIANT based on culture. The pregnant French eat stinky, unpasteurized cheeses (and drink wine), which are giant no-nos for pregnant Americans; pregnant Americans are urged to consume lots of fruits and vegetables, while many restaurants in France won’t even SERVE pregnant women a raw salad because raw salad greens can carry e. coli. I received lists banning things from raw root vegetables (toxoplasmosis), to undercooked meat, to overcooked meat (cancer risk), to all forms of dairy and peanut products (allergy risk for the fetus), to strawberries (ditto), fish (mercury), any food you didn’t prepare yourself (can’t ensure safe handling didn’t result in food poisoning, or that foods aren’t mislabeled and have secret stinky cheese!), and a ton of other stuff. All of these are at least RATIONAL minimal risks (except perhaps the overcooked meat and the allergies, which were banned on the “better safe than sorry” theory), but the fact is that I don’t think that I should have to sit at home for nine months cooking organic brown rice for every meal and eating nothing else because EVERY OTHER FOOD ON THE PLANET IS ON SOMEONE’S BAN LIST.

    Many of the restrictions surrounding pregnancy have little to no basis in evidence; they’re based in moralism, hysteria, and paternalistic attitudes towards pregnant women. Witness above the several comments saying, “Why can’t you just abstain?” and “Women can’t be trusted to decide to have just one glass.” (Certainly true of some individuals, but some individuals can’t be trusted to follow any recommendations during pregnancy or otherwise — should we just lock them all up until they comply?)

  39. Kylara – good point and good rant, it gave me a chuckle.

    But a couple additions – bagged salad greens can contain – listeria, salmonella, ecoli. But my friend the microbiologist who does food testing says you can rinse the listeria off with cold water.

    And I think you forgot not cleaning the litter box (toxoplasmosis again). Probably it is an unreasonable risk to even own a cat, except there is some evidence that pet ownership lessens the risk of childhood allergies…unless it causes them.

  40. moderation says:

    @ Allison Cummings:

    I was using the “experimental drug tester, boxing, professional roller coaster rider” as what I thought were humorous and extreme examples of behavior I thought might hold risk to the developing child. I am pretty sure that pregnancy eliminates you as a possible participant in most drug trials, that most amusement parks have big signs which warn women against certain rides when pregnant and that you cannot get cleared to box prfessionally in any state while pregnant.

    And if your question is “If two 7 month pregnant women were found on youtube participating in an MMA fight would I want there to be a legal restriction against this?” The answer is: yes! Someone can correct me if I am wrong, but I believe there have been several cases of women found to be abusing drugs during pregnancy, placed in jail until their delivery. These have been in only the most extreme cases … often with a history of multiple previously damaged newborns and positive court mandated drug screening test. Where should the line be drawn? Patient autonomy vs the health of the newborn. I don’t know.

    My real point was to say that as there is no known benefit to alcohol consumption during prgnancy and definite documented risks, why would a physician ever say anything but abstainence is recommended? They shouldn’t.

  41. moderation,

    Your language was that women do not have the right to make these choices. Pregnant women are not free to make choices about their own bodies. If a woman is not free, then presumably she is in prison, or perhaps on probation. Or perhaps just on de facto probation, such that if I spy a pregnant woman doing something I disapprove of, I can make a quick phone call and get her locked up? These restrictions apply to any woman not known to be infertile or currently menstruating, presumably, because not all pregnancies are visible. In this country you live in, where women are not free, I would expect that men aren’t free either. If they are exposed to mutagens they might create defective embryos. If I see a man doing something hazardous I should be able to make a phone call and get him locked up too. Or maybe just sterilized?

    In fact, I do not believe that this fetus’ paradise exists in any country on earth. This is a fantasy, and quite an extreme position that you are promoting; I don’t see any moderation here.

    Sure, pregnancy creates ethical dilemmas because the mother and her embryo or fetus are not separable. In general we suck it up. The simple existence of an ethical dilemma does not annul the right to liberty or privacy for an entire class of human beings. In general, the rights of a woman to her own body take precedence over the rights of any embryo or fetus, potential or actual. You might not like it, but we are free.

  42. Harriet Hall says:

    moderation said “as there is no known benefit to alcohol consumption during prgnancy and definite documented risks, why would a physician ever say anything but abstainence is recommended? They shouldn’t.”

    The point is that “definite risks” are NOT “documented” for low levels of alcohol consumption. Recommending total abstinence is simply not supported by the evidence. Even if there is no known benefit to alcohol “as a drug,” alcohol is also a food with cultural and personal associations, and its use is pleasurable. The physician should tell the patient what the evidence says and let the patient decide.

  43. Calli Arcale says:

    An interesting post. Myself, I abstained through my two pregnancies, apart from a couple of sips of wine. (Literally, a couple of sips.) I enjoy a nice glass of wine, but given the uncertainty, I had no problem just waiting 9 months.

    micheleinmichigan:

    “While “moderation” may have his/her beliefs about a woman’s deeming a risk reasonable, I hope that he/she does not impose those beliefs on others.”

    Yes, my issue is “where does one draw the line?” Who draws the line for women? My sister worked through most of all her pregnancies.

    A great many of the restrictions that various societies (including our own) have placed upon women are justified by the rationale of protecting the fetus. Taken to its logical extreme, you get the Mideast culture, where women are entirely subordinate to men, who are expected to care for and provide for and defend them. Yes, there is a bit more to it, but the fact that women have the babies is the core of it, because it provides the notion that women have a specific role to fulfill, and therefore men must also.

    I have misgivings about criminal charges against women who used illegal drugs during pregnancy. Yes, it is harmful to the child, and yes, the drugs are illegal to possess or sell. (Notably, they are not actually illegal to use.) But where is the dividing line? There are cases of women imprisoned to force them to get prenatal care — an oddity, given the number of women who fail to get prenatal care not because of religion or philosophy but because of poverty. (Apparently we only care if the woman is *choosing* not to get care. If she just can’t afford it, or it’s 150 miles away from the rez where she lives, then too bad.) I do think it is wrong to smoke or use recreational drugs during pregnancy, as they are associated with known risks, and women should avoid sports with high risks of impact injuries in the last month or two. (Hockey is probably a bad idea.) But I do not think this is something we should legislate or criminalize. Women are *people* and people deserve to be allowed to live their lives with dignity.

    There is another side to this. Society demands perfect behavior from prospective mothers, and judges them harshly if they are found wanting. Is it really any surprise, then, that some women who do not feel they can live up to that or stomach the abuse decide instead to terminate the pregnancy? Not right, not good, but there it is.

  44. Dash says:

    Way back up at the top windriven made a point that hasn’t been picked up but I think is very important – in the case of pregnancy, or rather foetal development, does the dose make the poison or is there an argument for ‘critical moments’?

    I remember reading a study years ago, so I have no idea where, that CVS performed during 7-9 weeks is linked with limb deformities because it disrupts the placenta during limb bud formation. All of these studies seem to be based on long lengths of time, so wouldn’t pick up critical moments. I would be very interested in a study that looked specifically at short times known to be developmentally important to different body systems and then looked at those systems in the babies. I can see this would be very difficult!

    On FAS, having taught several very intelligent students with it, I would want to concentrate on something to do with focus and concentration, difficult in babies. Alternatively they tend to have distinctive facial features with very narrow pointy chins, although that is relative to the rest of their families not absolute. It’s also a personal observation, and although I worked in several different towns it’s quite conceivable most of the students I taught were related. So it could just be a family resemblance.

  45. moderation says:

    @Harriet Hall:

    There is a big difference between a plate of pasta and a glass of chianti. So when the patient says, “well Dr. Hall, I am just not sure … how much alcohol would you recommend would be safe for me to consume on a dialy basis?” It is fine in the abstract to say that every patient will look for you to simply lay out the scientific data and let them make a choice, however a lot of patients will be looking for your expert opinion … and what will you tell them? I will be saying that at this point there is no definitive safe level of alcohol consumption, therefore I would recommend abstinence.

    @Allison Cummings:

    I did not want this to be a discussion of autonomy, but … there are many times that we as a society decide to restrict a person’s autonomy for the the good of society. We don’t let people sell their children or their body parts, routinely kill themselves or participate in many unregulated activities. It is a specious argument to compare activities or behaviors will very likely or surely cause serious damage to a fetus (ie. my attempt at a humorous exmple of the professional boxing near term pregnancy) to a behavior that is only a theoetical risk (ie. your mutagen example) whether it is a man or a woman. Lets see if can avoid the hyperbole.

    In the case of drug and alcohol abuse (not just use), one can have an extreme libritarian veiw that no one should be restricted from any active at any time, but unless one is also willing to say that we as a society will not be picking up any of the cost to treat and care for these damaged children then, there is a financial cost to society, not to mention a lifetime cost to the child with FAS. If you could listen to the painful cry of an opiod addicted premature newborn going through withdrawals you might have a different point of view.

  46. Harriet Hall says:

    moderation asks “however a lot of patients will be looking for your expert opinion … and what will you tell them?”

    When doctors lay out the facts and there is no clearcut evidence to favor one path over another, patients frequently ask what the doctors would do or what they would want their loved ones to do. I would tell them that I personally decided to drink only on special occasions and not to exceed two drinks a week but my decision was based on opinion and not on hard evidence and that most other doctors recommended abstinence while some thought larger amounts of alcohol were probably safe.

  47. moderation – “In the case of drug and alcohol abuse (not just use), one can have an extreme libritarian veiw that no one should be restricted from any active at any time, but unless one is also willing to say that we as a society will not be picking up any of the cost to treat and care for these damaged children then, there is a financial cost to society, not to mention a lifetime cost to the child with FAS. If you could listen to the painful cry of an opiod addicted premature newborn going through withdrawals you might have a different point of view.”

    Firstly – the libertarian argument – strawman – no one was say that there should be no restrictions at anytime.

    Secondly – What evidence do you have that making laws or putting pregnant women who abuse substances into monitored custudy will result in fewer children born with long term drug/alcohol related deficits? Since you are mentioning the cost to society? What would be the cost of this law and enforcement be? Do you have an estimate on what kind of chilling effect such a law would have on women voluntarily coming forward for rehab? What is the cost and relaspe comparison for addicts who come forth voluntarily vs involuntarily?

    Do you feel comfortable that we are currently offering sufficient social and medical services to women of child bearing age with drug issues or mental health issues that can lead to self-medicating? How about services for 18 year olds leaving foster care, that could be considered high risk? Most of those services have been cut in the last few years in many states. How do you plan on paying for this plan, what services are you going to cut?

    The law you are purposing seems more punitive than productive to me. Sometimes a law can make things better, sometimes it can make them worse.

    Pragmatically – I have heard it’s nearly impossible to have a law on the books that says a fetus has rights to care without having anti-choice applications.

  48. lkregula says:

    Considering that there have been cases within the last couple of years that have removed children from custody of a mother who refused a c-section, or legally confined a woman to bed rest so she wouldn’t work in a “risky” profession while in late pregnancy with some complications, I have a very hard time hearing that the lack of definitive evidence on the dangers of alcohol means a woman should abstain for nine months (or more if she’s lactating). Women are the people in this discussion, not the fetuses. Rights are granted to “people”- at birth, not before. And there is a very good chance for some benefit of alcohol. It is a depressant, slows heart rate/lowers blood pressure, so if high blood pressure is a problem for a woman, then it makes sense that a glass on occasion might be a good thing. Personally, I was going through a lot of stress when I was pregnant with my son, so my care provider suggested a glass once in a while when the stress was really bad. Now feel free to lock me up for infringing on my son’s rights. Should women try their best to care for the fetus they’re carrying? Of course, if for no other reason than they’ll more than likely be the one caring for the child later on, so they should try to avoid things that will make the child more difficult to care for.

  49. moderation says:

    @ micheleinmichigan:

    I suggest you go back and read my post more carefully …

    1. Allison Cummings response to an earlier post of mine seem to me to indicate that she felt the govt should NEVER have the ability to restrict that chosen activity of a pregnant women … even when it came to my attempt at the humorous (or not so much) example of the “professional boxing pregnant women”. I would call that in complete agreement with the strictest form of libitarianism.

    2. I never indicated that I thought a woman SHOULD be put in “monitored custody” … I was giving an example where the govt has already placed restrictions on the activities of pregnant women. I could just as easily have directed you to laws on the books restricting other activities by pregnant women. I feel fairly confident that in the states that do license professional boxing, there are legal restrictions on pregnant women boxing … therefore, there are lines drawn and the question is just, where will society choose to draw that line.

  50. MsFortune says:

    # Kylara – I am 25 weeks pregnant. I am going to have a toast to your post.

    “Many of the restrictions surrounding pregnancy have little to no basis in evidence; they’re based in moralism, hysteria, and paternalistic attitudes towards pregnant women. ”

    I, too, am surprised by some of the comments above. I am more than just a vessel to carry my husband’s child. I am a person with my own wants and needs, and those wants and needs include beer and sushi. And I will abstain if someone can convince me, with science and fact, not just out of our seemingly endless need to infantilize and control women, that this is needed.

    Thank you, SBM, for this post, and for shining light onto this topic. I’m sad that the evidence is not conclusive, but I feel more comfortable drinking now. It fits what my attempts at Google University came up with. So I will also toast your post.

  51. moderation on the control of women:

    “I don’t believe that once a decision to carry a pregnancy to term she has been made, an individual has a right to expose the fetus to whatever risk they would deem “reasonable.”

    You stated pretty clearly that no risk is acceptable and that a woman’s own judgement is never acceptable. And you stated it not in terms of whether you thought it was ethical, but in absolute terms of rights.

    Women never have the right to expose a fetus to any risk at all. This is a pretty clear statement that women do not have a right to their own bodies and an implication that the fetus has “rights” that always trump a woman’s.

    I’ll repeat what I said upthread: “Your language was that women do not have the right to make these choices. Pregnant women are not free to make choices about their own bodies. If a woman is not free, then presumably she is in prison, or perhaps on probation.”

    If you are American, are you stating that the constitution (liberty and the pursuit of happiness; security of person) applies to fetuses but not women? Are you stating that the laws on the books in all your states allow for protective custody of any woman doing anything at all that might be interpreted as a risk to a fetus? If not, what are you stating? Because I do not believe you are factually correct.

    If you are stating that even if women are free to make choices you believe we should not be, there are a number of practical reasons to suck it up that make your proposal impractical.

    And as Calli Arcale pointed out, why would you propose that an individual woman give up all her rights to her body as soon as there’s a fetus in it, in the absence of any obligation of society to ensure that the same woman has access to adequate food, medical care, and so on?

    Have you thought through the implications? What does the fetus-friendly world you fondly imagine actually look like? Personally, I can’t imagine living in a world where pregnancy would deny me the right to make choices and automatically suspend very fundamental rights under the law. You say that you’re pro-choice, but I can’t see how you could keep abortion legal in this world.

  52. moderation proving that women do not have rights to their own bodies:
    “I feel fairly confident that in the states that do license professional boxing, there are legal restrictions on pregnant women boxing.”

    You might want to look that one up. The formulation of the law that I am familiar with is that people generally can refuse to do dangerous work whether or not they are pregnant. This can be in worker protection legislation or other forms. For instance, in my jurisdiction (Québec) maternity leave is covered under EI (Employment Insurance) which is pretty much universal: even the self-employed are covered. There’s the basic maternity & parental leaves (up to almost a year, I think) and then there’s preventive leave. If your doctor thinks it’s dangerous for you to be working while pregnant you can apply for preventive leave and get EI benefits to take leave while pregnant.

    I am not aware of laws on the books around here that make it illegal for a woman to box. If you think there are some, feel free to enlighten me. However, a professional boxer is empowered legally and practically to refuse to box if she or her doctor thinks it’s dangerous. The choice is hers.

    I do know that despite your assertions to the contrary, it’s definitely not illegal here for pregnant women to consume alcohol.

  53. moderation says:

    @Alison Cummins:

    What does THIS have anything to do with our “discussion”:
    “If your doctor thinks it’s dangerous for you to be working while pregnant you can apply for preventive leave and get EI benefits to take leave while pregnant.”

    I think that is great! We were talking about the case where a woman WANTS to participate in an obviously dangerous activity, not one where she is trying to get leave from a dangerous work environment.

    BTW, nice attempt paint everyone one with a broad brush of being anti-women’s rights. As I pointed outed in a previous post the gov’t already restricts the activities of both men and women:

    “We [society] don’t let people sell their children or their body parts, routinely kill themselves or participate in many unregulated activities.”

    I have no idea what goes on in Canada, a pregnant woman CANNOT professionally box in the state of Nevada. In fact there are many restrictions related to health status – including having only one kidney or mental illness.

    So, good luck to all those “professional boxing pregnant women” – because I think they will find even in Canada, they will not be able to practice their chosen profession until after delivery. In fact, Ms. Cummins, why don’t you contact your local gov’t body that oversees professional boxing let them know that you want to be licensed to box, tell them you are 7 months pregnant and get back to me on what they say.

    Comment all you want further, but I am done with the esoteric discussion of “professional boxing pregnant women”. As I said before, when I was asked to provide example, “professional boxing pregnant woman” was an attempt to pick the most outrageous, extreme and possibly humorous example of a behavior that I thought a woman should legally be restricted from while pregnant. It appears quite clear that you (Ms. Cummins) feel there is NO activity SO dangerous that there should be a restriction placed on a prgnant woman’s right to participate … no matter how outrageous. It occurs to me there will always be someone willing to argue any point …

  54. “We [society] don’t let people sell their children or their body parts, routinely kill themselves or participate in many unregulated activities.”

    A child, once born, has human rights individual from the parent’s. You don’t really seem to be getting the idea. But the Supreme Court ruled in 1973 that the fetus does not have the rights of a legal person. Once born (or possibly when viable, the Supreme Court left the door open) the baby does have the rights of a legal person. They also explicitly pointed out the the women’s right to privacy.

    “The principal thrust of appellant’s attack on the Texas statutes is that they improperly invade a right, said to be possessed by the pregnant woman, to choose to terminate her pregnancy. Appellant would discover this right in the concept of personal “liberty” embodied in the Fourteenth Amendment’s Due Process Clause; or in personal, marital, familial, and sexual privacy said to be protected by the Bill of Rights or its penumbras … or among those rights reserved to the people by the Ninth Amendment …”

    I’m not sure what you mean by routinely kill themselves…like suicide on Tuesday’s at 4:00pm? But yes we do have some controls to protect the mentally ill, those same controls (but no more) apply to pregnant women.

    As to the question of boxing and commerce licenses in Las Vegas. Do you imagine that regulating the consumption of alcohol or drugs for pregnant women is going to fall under commerce licensing requirements? So we’ll require people to get a license before they conceive? And then withdrawal the license if they break the licensing requirements? I just don’t think people are going to go for that, and pretty sure that darn Supreme Court would have something to say.

    Also, since you seem to want to paint the folks who disagree with you as some sort of fringe libertarian group, there are a few health organizations that have stated policies against criminalizing substance addiction while pregnant.

    They are…
    the American Medical Association
    the American Academy of Pediatrics
    the American Public Health Association
    the American Nurses Association
    the American Society on Addiction Medicine.

    Also
    Center for the Future of Children
    The March of Dimes
    As the March of Dimes explains: “targeting substance-abusing pregnant women for criminal prosecution is inappropriate and will drive women away from treatment.”

    http://news.google.com/newspapers?nid=886&dat=19910101&id=8QghAAAAIBAJ&sjid=QFwEAAAAIBAJ&pg=6843,37800

  55. Also moderation – “where will society choose to draw that line.”

    Seems I’m always harping on this in SBM but, a demoncracy is not just a majority rules structure, separation of powers and all that. In the U.S. there are individual rights that are outlined in the Constitution. The majorities’ or societies’ desire to “draw that line” does not take precedent over the rights of the individual.

  56. “But yes we do have some controls to protect the mentally ill, those same controls (but no more) apply to pregnant women. ”

    Should be, “Those same controls apply to pregnant women who are mentally ill.” I did not mean all pregnant women – whoops.

  57. moderation says:

    @micheleinmichigan

    You are correct, selling your child is a poor example, but selling your organs is a perfect example, or wearing a seat belt – and that IS regulated by the gov’t. By “routinely kill themselves” I meant committing sucide, without a diagnosis of terminal illness. To my knowlege, that IS against the law in most/all states.

    Lets see if you can stick to the point at hand: I was asked to name an activity that I would be OK with the gov’t restricting a pregnant woman from participating in and I said “professional boxing”. BTW, nice attempt at a “bait and switch” maneuver, but I never advocated licensing people to become preganant or to consume alcohol while pregnant.

    For the record I do believe the should be some reasonabale limits, be it professional boxing or working where there was known exposure to teratogens. I see a big difference in an adult choosing to participate in an activity who consequences come back to them and an adult who partipates in an activity whos’s consequences are visited on what will be an innocent second party (I am speaking of late term pregnancy). Be reminded, I am NOT in any way implying I am the all knowing OZ and should decide where lines should be drawn, but rather am arguing only that there are legitimate societal reasons to draw a line. Why don’t you and Ms. Cummins both answer a simple question and then we can move on from this converstion: Is there any behavior, activity or profession for which you would deem it to be appropriate for the gov’t to restrict a pregnant woman’s ability to particpate? Remember this is ANY activity?!

  58. In my opinion, any group that employees people that has a health standard for active participation/duty can reasonably include some phases of pregnancy along with other health requirements (such as uncontrolled asthma, organ failure, etc) as a disqualifier. The rational for this is because affected people can not adequately perform the required duties or because that duty would be considered too high risk for the employee. This could include, some active military service, some active firefighter service, etc.

    Understand though, this does not mean that a pregnant woman is banned from putting out a fire or shooting a weapon (within local laws for firearms.)

    Also pregnant women should be required by law to not kill, rob, assault, etc other legal people or infringe on their rights as required by the laws for the general population.

    Also pregnant women should be included in all mental health laws. If there is evidence that she is a danger to herself and/or others (sorry that only include people who have been born) (etc, the laws vary by state.) she should be subject to the same laws as the rest of the population.

    As to laws either banning or requiring particular behavior to protect a fetus, I can not imagine one that would not conflict with freedom of choice.

    I also do not think such a ban would help the health of the children that are born. Something that I keep saying, but you keep ignoring. This makes me wonder if the goal is better outcomes for children or just more control of women.

  59. IQ is not a very sensitive measure to the theoretically modest impact of modest alcohol consumption on the developing baby.

    One problem is that you do not know the IQ that the exposed person would have had. IQ cannot be predicted by sibs within the range of msmt error, so you cannot use sibs as a comparison group.

    As it is, a decent IQ comes with a margin of error of several maybe 8 points either way.

    We have a challenge evaluating subtle differences in adults, such as ppl with emergent dementia. Oveall IQ is not good enough.

    And IQ does not get at executive function very sharply.

    So, a study to detect modest impact of modest alcohol needs a huge cohort design, where the resulst gets confounded by sociodemographic influences and other influences.

    I likes the one response: that if you go sober, and the child has some problem, you don’t have to wonder if it was the alcohol you drank.

  60. Walabio says:

    If a woman chooses to carry a baby to term, one chooses to act responsibly. If one does not act responsibly, she should be put into protective custody and sterilized after birth —— if she cannot use her right to reproduce responsibly, we should take away her right to reproduce.

    Speaking about irresponsible reproduction, men who leave a trail of babies behind them and people who reproduce on welfare should be sterilized. If people do not use their rights responsibly, we should take them away. This is not without precedent:

    If people do not use their right to be free responsibly, by let us say killing people just for watching them die, we take away the right to be free and lock them up in prison.

Comments are closed.