Alcohol during pregnancy

What should be the official advice for women about the consumption of alcohol during pregnancy?

On 11th October 2007 several news sources reported on the revised draft guidelines on antenatal care that were to be published by NICE (National Institute for Health and Clinical Excellence) in March 2008. These guidelines are reported to advise that there is “no consistent evidence of adverse effects from low-to-moderate alcohol during pregnancy (less than one drink or 1.5 units per day) but the evidence is probably not strong enough to rule out any risk.”

(NICE spokesman quoted by bbc.co.uk. This advice is broadly similar to the previous (2003) guidelines on antenatal care by NICE, which suggests that “[i]f you do drink while you are pregnant, it is better to limit yourself to one standard unit of alcohol a day (roughly the equivalent of a small glass of wine, a half pint of beer, cider or lager, or a single measure of spirits)”.

This recommendation became a news story primarily because it contradicted advice issued by the Department of Health a couple of months previously (the Pregnancy Book, published 24 May 2007 ), that pregnant women should avoid all alcohol, on the grounds that, since there is no generally accepted safe limit, the safest course of action would be not to drink any alcohol at all. As a footnote, it is worth pointing out that the media coverage seems to have had a tangible effect on the draft guidelines: when March 2008 finally arrived, the wording was indeed changed to be more in line with the Department of Health guidelines.

On other pages we summarise the issues involved and the development of the story in the media.

Commentary

The newspaper reports and subsequent discussions on the official advice to pregnant women not to drink any alcohol is interesting for several reasons. First, we have two government agencies issuing apparently contradictory advice, which is naturally enticing to journalists. Second, the discussion moved away from evaluating the scientific evidence that formed (or should have formed) the assessment of the risk involved. Because the evidence at the end is fairly inconclusive, the difference between the two sets of advice rests on different social priorities, so that the arguments do not need close inspection of the scientific evidence to function.

One is the moral view which argues that alcohol is at best a dispensable pleasure, at worst a sin anyway, and that pregnant women who drink needlessly endanger their future children for the sake of their own pleasure. Added to this view is the precautionary principle: while we don't know what the precise safe limits for alcohol consumption really are, it is safer to abstain completely rather than face any risk at all, even if there is no evidence that small amounts of alcohol are at all harmful. Whatever the value of the evidence, no alcohol definitely means no risk to the child.

safer to abstain?

On the other side of the discussion, there is the argument against the precautionary principle itself. First, people can question whether the blanket abstinence campaign will reach those women who are most at risk anyway – it is argued that the abstinence advice is going to be followed mainly by people who already drink cautiously anyway, rather than those who really should restrict their alcohol intake. The precise mechanisms at work about how the abstinence advice works is a matter of social science research, and independent of the underlying scientific evidence of the original matter. Even so, there is still the argument that, in the absence of evidence, the complete abstinence advice is patronising to women as it is saying in effect that they cannot control themselves. The argument is even made that the abstinence advice derives from a moral, rather than scientific position, and that therefore the drink issue is not about risking the health of the future child, but about drinking in general.

There are several other things to consider: the moral and emotional impact any reported risk to children has compared with risks that only involve adults; the fact that the potential victim has no choice in the matter, which makes a risk much more unacceptable than a risk that the potential victim chooses for him or herself. Also, precisely what do we want to achieve with the advice? If it is part of a larger campaign against alcohol, for example, then the complete abstinence advice is more likely to be made because it ties in with the larger set of aims.

All of these arguments are worth having, and they are valid social concerns that need to be addressed even if they are not necessarily influenced as strongly by the scientific evidence as the media representation suggests. The scientific evidence can merely shift the emphasis of the debate – the stronger the evidence of harm to the future child with even low level alcohol consumption, the more the debate will shift towards advising abstinence. However, how strong the evidence has to be for a particular piece of advice to be the “right” advice is, as we hope this episode shows, unclear.