Can we tolerate pragmatism in maternal health policy about alcohol use in early pregnancy?

This week our research team published findings describing how women change their use of alcohol around the time of conception and in early pregnancy. The research was motivated by 2016 guidance from the Centers for Disease Control and Prevention that recommended that women who are planning a pregnancy or who might become pregnant “not drink alcohol at all.” National media coverage of the guidance ran the spectrum from pragmatic observations that it was not realistic and would be ignored, to feminist perspectives on shaming women who use alcohol and on the implicit assumption that women should shape their lives in anticipation of childbearing.

Recommending that those who could conceive should abstain from alcohol contains the implicit assumption that women who are planning a pregnancy would, as a matter of course, stop using alcohol while trying to conceive. Our analysis deconstructs the argument to examine one facet. We sought to determine if women who are planning a pregnancy typically abstain from alcohol and to describe when those who drink change their patterns of alcohol use. We found the vast majority of women with intended and unintended pregnancies rapidly reduce or eliminate alcohol use at the time of a positive pregnancy test. This suggests additional public health strategies could also be effective.

We did not set out to assail current recommendations. As neonatologists, an obstetrician, a statistician, and a MD/PhD student, we set out to describe what is happening and to adjust for biases that could blur the picture. Ninety percent of study participants reporting to an anonymous interviewer reported they stopped using alcohol, and 8 percent reduced. Planned or unplanned pregnancy, they did this early, near the time they missed their period. They were prepared to make a change and did. Well before entering prenatal care or having others aware of their status. They knew their bodies, confirmed pregnancy, and changed behavior.

The simple policy path for health education has been to preach: “no safe level of drinking in pregnancy.” This is likely wrong as are most absolutes. In reality the physiology is not nailed down. We don’t know how vagaries of individual genetics—such as whether you metabolize alcohol quickly or slowly—influence risk. We haven’t pinned down how developmental vulnerabilities of the embryo and fetus over time respond to different amounts, chronicity, and timing of exposure to alcohol. Did you binge on champagne at your sister’s wedding at 5 weeks of pregnancy or continue a pattern of several single glasses of wine each week for the duration? We know even less about how common levels of alcohol use translate to alcohol reaching the embryo in the earliest stages of pregnancy before there is a fetal heart beat or maternal-fetal circulation.

We do know that individual characteristics and patterns of use can interact with devastating consequences when an infant is born with fetal alcohol syndrome. We know this is not common among women with modest alcohol use but don’t know how or when in pregnancy the line is irrevocably crossed. Full scientific disclosure requires us to candidly say: “since we don’t know when or how much alcohol is safe, the best course is to avoid exposure.”

Enter human nature. We each view risk differently. Some feel the need to use antimicrobial hand gel through each day for safety while others provide healthcare to those with contagious conditions. We choose different behavioral risks—speeding or not, smoking or not, and we live lives—urban or rural, physical or office work, poverty or wealth—that put us in the paths of different risks.

One individual’s perception of negligible risk can keep others up at night. Add responsibility for a developing “other” to the mix and all bets are off. Do I relax into pregnancy as a natural state likely to go well or double down on vigilance to hold all risk at bay? We should not be surprised women have different decision thresholds for how they modify alcohol use. Some will stop in advance and others will adapt when they perceive the need. I believe we can speak to both groups and not undermine the message. Women are savvy. Our obligation to support informed decision-making demands explanation not slogans.

Abuse and dependence on alcohol are not the topic here. These are the reason we screen for problem drinking in well-woman and prenatal care. The remainder of women who responsibly use alcohol need information about what is known and what is unknown so they can use that in their individual calculus of risk. Alcohol can be a teratogen. It can damage the embryo. Our best estimate from animal models and human exposure mapping is that the abnormalities of facial and brain development that go wrong in fetal alcohol spectrum disorders follow from insults to the neural crest cells that participate in forming the face and neural tissue and lay down the pattern for the brain. These are forming in the 6th to 8th week of pregnancy as clinically measured from the missed menstrual period.

More than 90% of women we studied stopped drinking when they had a positive pregnancy test and almost all of the others reduced to less than one drink each week on average. In this figure, dark gray indicates the number of women who stopped using alcohol across time and pale grey shows when they reported pregnancy testing, relative to the last menstrual period (LMP).

This timing leaves little room for error. Women who intend to change their use of alcohol to reduce risk of FASD need to use a pregnancy test, and retest as needed, right around the time of the missed period. We don't know this eliminates risk, and for many women with inconsistent timing of periods timing is tricky and likely unreliable.

We can’t get this message wrong. Even one child with lifelong disability is too many. But if the message is so rigid that we perpetuate an impression that the choice is all—quit before conceiving—or none—it’s just a gamble —we can’t share the urgency of the need for taking action early in pregnancy. If we don’t give the whole picture and trust women to understand it, we will have done more harm. More than one child will be harmed if women who are waiting to change their alcohol until after conception don’t get guidance about how soon they must know.

Early pregnancy testing is key.

Source Publication:

Pregnancy Intention and Maternal Alcohol Consumption by Pryor J, Patrick SW, Sundermann AC, Wu P, Hartmann, KE in Obstetrics & Gynecology, ePub 03/09/17

3-minute video summary of study: Vanderbilt Study Shows Early Pregnancy Awareness May Be Key Public Health Strategy

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Related Peer Reviewed Research Resources:

Prenatal alcohol exposure patterns and alcohol-related birth defects and growth deficiencies: a prospective study.

“The strongest associations [with FASD] were with timing of exposure in the second half of the first trimester (RR 1.25, 95% CI 1.14 to 1.36 for average number of drinks per day; RR 1.17, 95% CI 1.09 to 1.26 for maximum number of drinks in 1 episode). Similarly, thin vermillion border was most strongly associated with exposure in the second half of the first trimester. Findings with respect to timing of exposure [for other outcomes] were similar for microcephaly and reduced birth weight”

A review of the physical features of the fetal alcohol spectrum disorders.

“Embryologic studies have shown that early insults to these structures during the equivalent of weeks 7 and 8 of human development appear to determine apoptosis and consequent reduction of those early structures [associated with FASD].”