I am a member of several different listservs for clinicians, researchers and teachers of psychology and mental health topics. A hot button issue spurring a lot of discussion on one of these listservs is the group's reaction to a recent ABC News video segment (and published story on their website). This video segment depicted two women in their 30s who are 8 months pregnant with their first child. One woman has made the choice to not drink at all during her pregnancy, while the other drinks a glass of wine 4 or 5 days a week. In theory, I assume the story was supposed to present the pros and cons of drinking alcohol during pregnancy. In reality, the "take home message" of the story was that moderate drinking (of an unspecified amount) during pregnancy is okay.
This is an issue that draws an emotional reaction from many people- from pregnant women and their spouses; to parents in general; parents of children who have been affected by fetal alcohol spectrum disorders (described below); researchers/scientists, and health care professionals; and finally, "people on the street" who see a pregnant woman drinking. Clearly, the reactions may not always be based on the best available medical and scientific information, but rather, get intertwined with other emotionally charged ideas of self-sacrifice, personal freedom, and privacy issues.
Unfortunately, the ABC video segment did not provide the audience with additional research-based medical/scientific information that could help pregnant women make a more well-informed decision. Rather than presenting different viewpoints and data, the reporter interviewed only one "expert" (Dr. Moritz) during this story. This expert may be a wonderful practicing physician, but he made 2 statements that cloud the issue. The first statement was false, while the other was (hopefully) unintentionally misleading because it omitted crucial facts.
Problematic Point #1:
Dr. Moritz acknowledged that The American College of Obstetricians and Gynecologists and the March of Dimes recommend zero alcohol consumption during pregnancy. However, he went on to say that these recommendations are "very, very strict" .... and resulted from the fact that "there are no studies done."
This first point is problematic because we do have studies suggesting that alcohol can damage a growing fetus. It would be more accurate if Dr. Moritz had said that we don't have experiments of the double-blind placebo-controlled variety that would allow us to specify exactly how much (or how little), and when alcohol can be safely be consumed during pregnancy. Obviously, it would have taken a bit of airtime to tease out the meaning of this expanded sentence, but at least it would have been more accurate.
So, what exactly does my new longer sentence mean? A double-blind placebo-controlled experiment is a rigorously designed and tightly controlled type of study that is the gold standard in medical research. "Double-blind" means that neither the pregnant women or the scientists collecting the data would know the level of alcohol that participants received during the study. Being "blind" in this sense is important, particularly when the doctors and women go on to rate their babies and children on scales of emotional. social, and behavioral development. We want to know whether prenatal alcohol exposure causes long term problems (described more below), so we will be examining these kids across time using parent reports, doctor reports, etc. Across time, moms and doctors may unintentionally subtly bias their ratings if they know that the child being discussed was subjected to a little or a lot of alcohol prenatally. Even subtle biases can create problems in studies that can lead to making incorrect conclusions.
"Placebo-controlled" means that among the different groups of women being studied would be one group (again, both experimenters and participants would be "blind" to this fact) who received a placebo, or non-alcoholic version of whatever substance they were using as the "treatment". This is an important component of an experiment that allows a researcher to more precisely determine whether it's truly the alcohol and not something else that's causing the effects on children. If women in the placebo group (who drink no alcohol) have children who are identical to children coming from women who drink several alcoholic beverages per week, then it's awfully hard to conclude that alcohol is causing the problems!
In addition to the double blind placebo control, a "true experiment" would have to be designed as follows: 1) the experimenters would need to find a large group of women who agreed to participate 2) the potential participant pool would need to be as identical as possible before starting the study (women at the same stage of pregnancy, similar body weights, similar history of previous alcohol use, similar diets, etc.), 3) the participants would need to be randomly selected from the pool by a computer program (or another means) to ensure that everyone had an equal chance of being included in the study 3) selected participants would need to be randomly assigned to different study groups that would only differ with regard to the amount of alcohol they were consuming, 4) The method of giving the women alcohol would need to be tightly controlled and not be obviously different across groups (keeping participants and experimenters "blind"). In other words, it would be pretty clear what group you were in if you were guzzling 3 large goblets of wine while the pregnant woman next to you only had a shot glass full. Also, you couldn't simply tell the women to go home and drink one glass of wine 2 days a week. One woman's glass might be 3 ounces, while another woman might consume 7 ounces. All of these rigid study criteria would be designed to eliminate statistical biases that might influence the results of the study.
And that's only the beginning! As I alluded to before, in an ideal study, a participant would be followed across time as her fetus develops and grows (both in the womb and once he or she was out in the world). Because some effects of alcohol exposure are not readily apparent (see my discussion of Fetal Alcohol Spectrum Disorders below), participants' children would need to be followed into adolescence. Even then, the study would need to be repeated with other types of pregnant women (of different weights, backgrounds, etc) to figure out whether and how much other factors impact the influence of prenatal alcohol exposure on the development of the fetus and child.
I hope you can see where I am going with this...not only would this research be time consuming and difficult, but ethics boards (that review studies for potential ethical violations before allowing them to go forward) simply would not allow a researcher to proceed. Subjecting a group of pregnant women to this type of research simply to find out whether their children are harmed won't fly. The researchers proposing the study could not argue that the potential benefits of alcohol outweigh the potential risks. Obviously, alcohol is not designed to treat or cure diseases.
So, the best we can do to is rely on less precise studies that are available. And, the studies we have clearly indicate that alcohol easily passes through the placenta and is a teratogen, or potentially harmful substance. In other words, alcohol can harm cell growth. A single binge at a critical period in the growth of the fetus, and repetitive bouts of drinking can cause problems.
So, I disagree with Dr. Moritz. There have been studies conducted. However, I do agree that the type of studies that would allow us to provide guidelines about the exact amount (and timing) of alcohol consumption have not. So, we can't say that drinking any amount of alcohol during pregnancy "will always" cause problems for the fetus. That is also untrue. We can say, though, that the potential risk of harming a fetus is there. We can also say that whether or not a fetus is damaged by prenatal alcohol exposure depends on several factors, including: how a pregnant woman's body breaks down alcohol; the mother's weight, and the genetic makeup of the fetus and the mother.
Problematic Point #2:
In the ABC story, Dr. Moritz stated that in his many years of practice as an OB/GYN, he had never seen a case of Fetal Alcohol Syndrome (a collection of symptoms including abnormal facial features, growth deficiency, and central nervous system problems (e.g., impaired learning, memory, attention span, communication, vision, and/or hearing). I assume that he was trying to reassure the public by suggesting that the risk of having a child with FAS if you drink while pregnant is relatively slim. However, I am troubled by what the viewer may have taken from this comment.
Here's the problem with this point: just because Dr. Moritz has not dealt with this medical condition doesn't mean that the risk isn't real or that it doesn't occur. Unfortunately, Dr. Moritz did not go on to explain that FAS is only one end (the severe or most serious end) of the spectrum of disorders that can result from prenatal alcohol use. The whole group of problems, called Fetal Alcohol Spectrum Disorders (FASD) can range from mild to severe and include physical defects as well as cognitive, behavioral, and emotional problems. Some of these problems may not be apparent right away (e.g., infants with some of these disorders don't look any different than other infants at birth). So, even though Dr. Moritz hasn't seen a child with FAS, he might have delivered a baby with one of the other disorders without knowing it.
Labels used to diagnose the range of Fetal Alcohol Spectrum Disorders include FAS; Fetal Alcohol Effects (FAE); Alcohol-related Neurodevelopmental Disorder (ARND); and Alcohol-related Birth Defects (ARBD). The label FAE was commonly used in the past to describe a person with behavioral and cognitive problems who didn't have the physical characteristics to warrant a full-blown FAS diagnosis. This FAE diagnosis was eventually expanded and replaced by the labels ARND and ARBD, again keeping the idea that problems exist, but do not fit all of the criteria for FAS. ARND is used to describe people who have behavioral or cognitive problems, or a combination of both (e.g, learning difficulties, poor school performance and/or poor impulse control) resulting from prenatal alcohol exposure. People with ARBD have problems with the heart, kidneys, or bones; hearing loss; or a combination of these. According to the American Institute of Medicine (IOM), 0.6 to 3 babies born per 1,000 have FAS. The rates of less severe Fetal Alcohol Spectrum Disorders are much higher; ARND occurs in approximately 9 babies per every 1,000 live births.
Again, the research does not suggest that every women who drinks during pregnancy will go on to have a baby with a Fetal Alcohol Spectrum Disorder. Most won't. However, there is no failproof way to predict whether a person is one of the mothers who will drink while pregnant and have a child with FAS, ARND, or ARBD. The only failproof way to prevent this event is to avoid drinking during pregnancy. That's the reasoning behind the American College of Obstetricians and Gynecologists and the March of Dimes' recommendations and also the reason why this information should have been included in the ABC story.
If you would like more information on this issue, here are some resources:
Amerian College of Obstetricians and Gynecologists news release: http://www.acog.org/About_ACOG/News_Room/News_Releases/2008/Alcohol_and_Pregnancy_Know_the_Facts
Publication from National Institute on Alcohol Abuse and Alcoholism: http://pubs.niaaa.nih.gov/publications/DrinkingPregnancy_HTML/pregnancy.htm
Surgeon General's Report: http://www.surgeongeneral.gov/library/reports/index.html
Ebrahim SH, Diekman ST, Decoufle P, Tully M, Floyd RL. Pregnancy-related alcohol use among women in the United States, 1988-95. Prenatal and Neonatal Medicine 1999; 4:39-46.
Kodituwakku PW. Patterns of cognitive-motor development in children with fetal alcohol syndrome from a community in South Africa. Alcoholism: Clinical and Experimental Research. In press.
May PA, Brooke L, Gossage JP, Croxford J, Adnams C, Robinson L, Viljoen D. Epidemiology of fetal alcohol syndrome in a South African community in the Western Cape Province. American Journal of Public Health 2000; 90(12):1905-1912.
Morse BA, Hutchins E. Reducing complications from alcohol use during pregnancy through screening. Journal of the American Medical Women's Association 2000 Summer; 55(4):225 227.
National Institute on Alcohol Abuse and Alcoholism and Office of Research on Minority Health. Identification of At-Risk Drinking and Intervention with Women of Childbearing Age. A Guide for Primary-Care Providers. NIH Publication No. 99-4368; 1999.
National Institute on Alcohol Abuse and Alcoholism and Office of Research on Minority Health. Identification and Care of Fetal Alcohol-Exposed Children. NIH Publication No. 99-4369; 1999.
National Institute on Alcohol Abuse and Alcoholism and Office of Research on Minority Health. Personal Steps to a Healthy Choice: A Woman's Guide. NIH Publication No. 00-4370; 1999.
I am very interested in hearing your opinions and reactions to this story. Does knowing all of this information help you make a decision? If you are currently pregnant, share your ideas about why you choose to drink or not drink. I would also be interested to hear what doctors are currently telling pregnant women about this issue.
