Believe it or not I blogged eight whole years ago on the issue of alcohol and pregnancy, inspired by one of many rows I had with my mom while eating crêpes (I used to live a block away from a crêperie; it’s not weird). Yet somehow that one blog post did not permanently settle the issue for all human beings everywhere. As more and more of the women in my cohort get pregnant, I am learning that lots of them think the injunction to avoid all alcohol is just another moral panic–or, as my mom put it, a Scheme to Deny Women PleasureTM (she drank while pregnant with me). In fact, some of my very smart non-pregnant doctor-ly friends agree with them. I’ve endured quite a lot of scientific training since the demise of the blog of my youth, and it has emboldened me to question a lot of medical dogma. But this is one issue of which I am more convinced than ever.
One of the frustrations of being pregnant is that it involves being surrounded by people who believe it is their god given right–nay, their duty–to tell you what to do. I’m not trying to add myself to that list. Let me be very clear: I am not trying to tell any woman whether or when to drink. But I do want every woman who faces this decision to understand the issues clearly, so that she can decide without everybody shouting.
You will have realized by now that this is a Serious Post, so if you would rather scroll down to the scrotum jokes, now’s the time. Everybody else with me? Let’s go on.
First, let’s talk about what is and isn’t known. Fetal Alcohol Syndrome exists; I don’t know of any mainstream dispute to the claim that heavy prenatal alcohol exposure is linked to risk of a constellation of developmental problems. Drinking at different points in the pregnancy can confer risk of different outcomes, depending on what parts of the embryonic/fetal body or brain are forming at the time of the exposure. Here’s a link to a review of some of the research; I picked this article because it should be publicly available to everyone, but there’s some pretty obnoxious and sexist language in the “Expert Commentary” section, so maybe steer clear of that.
The controversy surrounds whether drinking smaller quantities should be considered safe. Actually, the authors of that review I linked to don’t consider this an open question, but let’s assume that for whatever reason you don’t find their argument satisfying (like, for example, they undermine their credibility by making themselves sound like supercilious jerkweeds). I will, in an abstract way, represent the consensus and the controversy like this:
Now I’d like to complicate the picture a bit. There is some evidence that within the category of “heavy drinking” (and how that’s defined is a whole other issue but I’m not getting into it here), a lot of heavy drinking is riskier than a little. One binge is risky but two binges is more so and three binges even more so. This is called a dose-response relationship, and I’m going to simplistically represent it, along with the uncertainty about the risks posed by lower doses, like this.
So the question posed for pregnant women, and the clinicians who advise them, is what do they do with that big question mark area? When you’re not sure if mild/moderate drinking is risky or not, how should you act? It’s tempting to say “Well, we don’t know the answer, so I’m not going to make any decisions right now,” but that’s never really true. You either decide to drink or you don’t (assuming you are not, in fact, addicted to alcohol, another issue I won’t be touching on today). I would argue that if you abstain from drinking altogether, you are behaving as though there is a dose-response curve at all levels of alcohol exposure. One drink is risky, but not as risky as two, etc. You are acting as if the question mark would be filled in with the following relationship.
If, on the other hand, you decide that mild/moderate drinking is safe, you are assuming that low doses of alcohol confer no additional risk until some threshold is reached, and then the dose-response curve picks up somewhat like this:
Either of these relationships is plausible. Occam’s razor might point to the simple linear relationship as being more likely, but I don’t actually care. From my perspective, what’s important is that alcohol during pregnancy is “safe” only if you can definitively rule out the linear dose-response relationship at low doses. I see lots of reasons to be uncertain that low levels of alcohol are harmful, but I don’t see lots of reasons to be certain that it’s safe.
A person could understandably decide that until there is definitive “proof” that something is harmful, we should act as though it is benign, especially if that something is important to her. But that also makes her vulnerable to exploitation by bad actors. As long as they can can convince people that the danger of their product is a source of controversy, they can keep selling it–hence the tobacco executive who asserted, “Doubt is our product.”
In making this decision, every pregnant woman should understand that if she chooses alcohol during pregnancy, it isn’t risk-free just because the risks are poorly understood. It means she’s hanging her hat on that wonky old curve at the bottom.
Now if you’ll excuse me I’m off to pour myself a glass of wine.