Advocating alcohol abstinence to pregnant women: some observations ...

1. Advocating alcohol abstinence to pregnant women: some observations about British policy Pam Lowe, lecturer in sociology, University of Aston and Ellie Lee, senior lecturer in social policy, University of Kent

3. A new departure? The move to recommend abstinence is notable for two connected reasons: It runs against the general grain of British health advice which is represented as �evidence based� and tends to focus on risk-awareness/risk-reduction (not �saying no�). It was justified on grounds that were manifestly not evidence based

4. The US dimension: the origins of abstinence policy Abstinence policy dates from 1981 in the US; the Surgeon General then advised, �women who are pregnant (or considering pregnancy) not to drink alcoholic beverages and to be aware of the alcoholic content of foods and drugs� The new official advisory reflected the emergence of a manifestly medical framing of what had previously been a moral concern. At the centre of this �medicalisation� process was the condition Fetal Alcohol Syndrome (FAS).

5. FAS/FASD FAS described as a rarely occurring condition associated with specific subgroups of the population. By 1981 (and even more so subsequently) FAS �expanded� to FASD which includes PFAS, ARBD, ARND. FASD not a diagnosis, but a �diffuse� set of problems caused not by alcoholism, but by �any and all drinking in pregnancy� (Armstrong 1998). Concern not or not only with maternal alcoholism, a medical condition but with consumption of alcohol a substance (Golden 1999; 2005). The problem of drinking in pregnancy evolved from an unusual medical condition �diagnosed by doctors and dealt with through effective management of pregnant women� into �a public health problem that required educating women not to drink during pregnancy� (Golden 1999). FASD as a �democratised� �equal opportunity� disorder� (Armstrong and Abel 2000).

6. Evidence and policy There is no direct line from �the science� to abstinence advocacy; policy and evidence in no clear relation Abstinence advocacy based on the moralisation/politicisation of science has been represented as typically North American, standing, �[In] stark contrast to the official advice offered in other countries� (Armstrong and Abel 2000, p277).

7. Abstinence and British policy DH first made alcohol and pregnancy an overt policy issue in Britain through advice issued in 1995. Recommended that: �Women who are trying to become pregnant or at any stage of pregnancy� should limit drinking to �one or two units of alcohol once or twice a week� to �minimise risk to the fetus�. These women should �avoid episodes of intoxication�

8. From uncertainty to abstinence advocacy The official message then was that a distinction can be made between occasional, light drinking and �intoxication� in regard to �risk to the developing fetus�. Statement of that year referred to �Fetal Alcohol Syndrome�, describing this as a condition �only seen in the offspring of alcoholic women�. Advice stated that: �adverse effects on cognitive and behavioural development might be observed as indicators of ethanol-induced damage in the offspring of women with lower ethanol intakes.� In 2007 speculation/uncertainty replaced with definitive support for abstinence before and during pregnancy

9. Policy rationale In so far as evidence was cited in 2007 to indicate that drinking at low levels is harmful: �The National Organisation on Foetal Alcohol Syndrome [NoFAS] estimates for the UK as a whole that there are more than 6,000 children born each year with Foetal Alcohol Spectrum Disorder [FASD]�. NoFAS is a North American lobbying organisation, whose British affiliate NoFAS UK was established in 2003 No discussion of the statistic �more than 6,000 children born each year with FASD� can be found on NoFAS� website. According to The NHS Information Centre it was generated by extrapolating estimates of the incidence of FASD for �western countries� and combining these with the official estimate of 700,000 live births in Britain each year (HES online 2007). The official estimate of the incidence of all birth defects is around two percent (in the region of 14,000 affected births). It appears NoFAS is attributing almost one half of these abnormalities to alcohol consumption in pregnancy.

10. Policy rationale Other justification overtly not evidence-based: �We have strengthened our advice to women to help ensure that no-one underestimates the risk to the developing foetus of drinking above the recommended safe levels�.The advice�.is now straightforward and stresses that it is better to avoid drinking alcohol completely� (DH 2007).

11. NICE guideline (2008) The group who developed new guidance assessed evidence regarding the effects of �low to moderate� consumption (less than 1.5 units per day) and �binge drinking� (defined as five or more drinks) for ten postnatal outcomes. No strong evidence for any outcome of a detrimental effect of either form of alcohol consumption. The only evidence of �harm� associated with low-to-moderate intake was described as �limited and poor quality� was this was �possibly a slight increase in miscarriage� (our emphasis). �Limited poor-quality� evidence that �binge drinking may be associated with neurodevelopmental harm�. In most cases no association was found between drinking and postnatal outcomes. For �growth outcomes� it was noted of studies that �several report a protective effect of low-to-moderate alcohol intake compared with no alcohol during pregnancy�. 

12. Response to NICE The guidance states: �Pregnant women and women planning a pregnancy should be advised to avoid drinking alcohol in the first three months of pregnancy if possible because it may be associated with an increased risk of miscarriage�.Women should be informed that getting drunk or binge drinking during pregnancy may be harmful to the unborn baby�. Gives priority to the effects of alcohol indicated by specifically �limited� and �poor quality� evidence. In later statements NICE officials have advised abstinence: Gillian Leng (Chief Executive of NICE) argued, it was best to send a �clear message� and stated she thought the new guidance, ��.reinforces the advice that came out last year. Women should be advised not to drink�. RCOG welcomed NICE�s statement. RCM stated: ��our advice is to remove all doubt and avoid alcohol whilst pregnant, and for women to stop drinking alcohol if they are trying to start a family (our emphasis)� (RCM 2008).

13. Features of the new policy approach Policy and medical organisations have decided it is best to circumvent uncertainty associated with evidence and simply associate any alcohol with harm.

14. From risk to harm: making the unknown known A modus operandi is developing in which policy in some instances circumvents the problem of uncertainty by simply associating what is unknown with certain danger, and acting accordingly; in other words risk assessment has been replaced with worst-case scenario thinking

15. Health advice as lifestyle rules Doing the right thing: �Just because you�re pregnant, your life doesn�t need to be on hold. You still see the same people and do the same things � which, for many of us, include having a drink. But things aren�t quite so straightforward now. You know that everything you eat and drink can affect your baby�� (Know Your Limits 2007b, p3, our emphasis) Drinking when pregnant as �choice�: if the woman finds herself unable to abstain, she must pay focused attention on precisely how many units is being poured into a glass (�one to two units only�) and diary keeping regarding frequency of consumption (�once or twice a week�). �Light infrequent drinking� is definitively not having a drink when you feel like it, but a tightly scrutinised activity performed highly deliberately. Doing the right thing

16. Are we all pregnant now? There are good reasons why the message �abstain� has been communicated to pregnant women, rather than other groups. �Playing safe� by taking no risk, however small, has become �common sense� when babies and children are involved. Abstinence policy simply takes one step further the already dominant �safety-first� approach to parenting in Britain and applies it to the �unborn child�. Official rejection of the cultural validation of drinking in general as a pleasurable and important part of life. Drinking can be easily represented as an entirely dispensable part of life for pregnant women, associated with no legitimate benefits: �It�s only nine months�.

17. Expansive dynamic In the US, the newest advisory urges: �women who are pregnant or who may become pregnant to abstain from alcohol� (HHS Press Office 2005). DH focuses on women planning to conceive as the non-pregnant group that should abstain, rather than any woman who �may become pregnant�. (The British Medical Association has, however, adopted exactly the same language as that found in the US advice). Uncertainty again justifies messages about harm: �Nobody really knows how much alcohol is �safe� to drink before your chances of conceiving are reduced�.If you are trying for a baby, it�s advisable to avoid alcohol. If you choose to drink, you should drink no more than one or two units, once or twice a Week� (Know Your Limits 2007) Non-pregnant women are given the identical advice to women who are already pregnant: �If you are trying for a baby, it�s advisable to avoid alcohol. If you choose to drink, you should drink no more than one or two units, once or twice a week�. Prospective fathers do and should abstain �supportively� (Drink Aware 2009). Some arguing that information about FASD should be embedded in �parenting education� for school children and built into larger anti-alcohol campaigns (BMA 2007).