• There’s plenty of blame to go around with the new CDC recommendations for alcohol and pregnancy

    I feel like a lot of my blogging has been reactive this week. Someone says something, people get outraged, ask me what I think, and then I wind up here. So be it.

    The CDC weighed in on alcohol and pregnancy yesterday. This should be relatively straightforward. It’s pretty widely believed that if a fetus is exposed to alcohol while in utero, it has a greater-than-zero risk of developing fetal alcohol syndrome. FASD is a collection of issues which include low birth weight and growth, and problems with organs such as the heart, kidney, and brain. Kids with FASD can have learning disabilities, communication issues, and a lower IQ. The problems can last a lifetime.

    That said, there are a number of holes in our knowledge base that make preventing this difficult. No one knows how much alcohol is needed in utero for a child to develop FASD. No one knows when the exposure makes a difference. No one knows why some women can binge drink during pregnancy and have a normal child while others might drink much, much less and have a child with problems.

    The American Academy of Pediatrics’s solution has been to declare that no amount of alcohol is safe during pregnancy, that there is no time during pregnancy that women can drink, and that no type of alcohol is ok. Although that’s not as widely accepted in other parts of the world, it’s felt like women in the US took that in stride without too much controversy. I know women who choose to drink the occasional glass of wine during pregnancy, but most women I know seem to abstain altogether during pregnancy.

    Clearly, I don’t know a random selection of Americans, though. According to the CDC, about 10% of pregnant women report some alcohol use and about 3% report binge drinking in the last month. Pregnant women most likely to drink are 35-44 years old, not married, and college graduates. Those who report binge drinking in the last month say they did so between 4 and 5 times, more even than nonpregnant women.

    I’m a “rate limiting step” guy. If we want to prevent FASD, starting with these women (who aren’t rare) might be a good start. Expanding to those who are still drinking alcohol might be the next place to go. But the CDC decided to go whole hog and recommend that no women who might possibly become pregnant should drink. This includes, of course, pretty much all women who have yet to go through menopause:

    More than 3 million US women are at risk of exposing their developing baby to alcohol because they are drinking, having sex, and not using birth control to prevent pregnancy. About half of all US pregnancies are unplanned and, even if planned, most women do not know they are pregnant until they are 4-6 weeks into the pregnancy. This means a woman might be drinking and exposing her developing baby to alcohol without knowing it. Alcohol screening and counseling helps people who are drinking too much to drink less. It is recommended that women who are pregnant or might be pregnant not drink alcohol at all.

    The subtitle of this article is, “Why take the risk?” and it’s part of a genre of “won’t somebody think of the children?” that leads to the “if just one child can be saved” thinking that winds up with the conclusion that all women should just be plugged into Matrix-style birthing chambers once they hit puberty, until they hit menopause. That’s clearly how you prevent anything from happening to a baby in utero, ever. Do I need to bring up cars? We do things every day, EVERY DAY, which increase the risk of death to children.

    You need to weigh risks and benefits. What is the prevalence of FADS? Even the CDC can’t decide. In their Data & Statistics section, they say that some records can identify 0.2 to 1.5 infants with FADS for every 1000 births. A more recent study found 0.3 out of 1000 kids 7-9 years of age has FADS. Other in-person assessments found that 6-9 per 1000 kids might have a FADS.

    But their new infographic proclaims that “Up to 1 in 20 US school children may have FADS.” Huh?

    Moreover, their other infographic says that women who drink too much have a higher risk of injuries/violence, sexually transmitted diseases, and unintended pregnancy. That has caused the blogosphere to lose its s#$t, and I can’t blame them. The alcohol doesn’t CAUSE these things, and the CDC knows it. This is an association, and it’s part of a pathway, but the way they went about talking about it is being interpreted as victim blaming.

    Why couldn’t the CDC just say that drinking too much causes you to lose control of your decision-making skills, which can lead to regret? For that matter, why is this part of the FASD discussion at all? It comes across as fear mongering about alcohol, period. If we go this route, why not just go back to Prohibition in an attempt to prevent FADS?

    I get what the CDC is trying to say here. They’re saying that women can become pregnant if they’re having sex and not on birth control (true). Many women are pregnant and don’t know they are (true). If we want to limit the chance of a baby having FADS, we should try and limit the number of women who drink, thinking they’re not pregnant when they are (true). So women should think about being sexually active without birth control while they are still drinking alcohol in their life.

    Unfortunately, that message didn’t get across. But before I blame the CDC completely, let me add that I don’t find the coverage by many in the media to be fair. Instead of trying to inform the public, talking about how the proper message should be getting across, too many are quick to use this as a “gotcha” moment to attack the CDC for their communication skills.

    If we want to reduce FADS, and get the most bang for our buck, it’s worth starting with the too-many women who binge drink while they’re pregnant. Their fetuses are likely at highest risk. It’s probably worth talking to women who drink at all during pregnancy, to tell them we don’t know the amount or time that alcohol is safe, so that they can make an informed decision about drinking. It’s even worth telling women who are sexually active without birth control that if they think they might be pregnant, they should stop drinking.

    Going beyond that with moralizing, shaming, complicating, and embellishing tactics likely doesn’t help.


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