Most pregnant women follow medical advice on forgoing alcohol, but what is the best way to reach those who don't? Photo / 123RF
Harsh measures, or even threats of them, can lead to the avoidance of prenatal care entirely.
In many areas of health policy, the best of intentions can lead to more harm than good. Such is the case with America's approach to alcohol and pregnancy.
The best evidence shows that punitive policies — such as equating drinking while pregnant as child abuse and threatening to involve child protective services — can dissuade women from getting prenatal care.
Fetal alcohol spectrum disorders refer to a collection of problems in babies and children. These include low birth weight; impaired growth; and problems in the heart, kidneys and brain. Children can have developmental delays, communication difficulties, learning disabilities and lower IQ. Some of these last a lifetime.
It is hard to know how many American children are affected. Studies done by the Centres for Disease Control and Prevention have estimated that between 2 and 15 infants per 10,000 born in the United States have fetal alcohol syndrome, the most severe form of the disorders.
Some community-based studies that use the broader definition of the disorder have found more affected children, up to 5 per cent.
We know that infants of women who drink alcohol in pregnancy may develop these disorders. The problem is what we don't know. We don't know the level of alcohol exposure in utero that could cause a child to develop these disorders. We don't know if the timing of the exposure matters. We don't know why some women who drink little might have a child who is affected, while some can binge drink during pregnancy and have a child with no apparent problems.
Because of this, most medical organisations, including the American Academy of Pediatrics and the CDC, recommend that women forgo alcohol during pregnancy. The only dose known to be "safe" is none, they say, and therefore women should not drink at all.
Many women in the United States comply with this directive. But a significant number do not.
A study published in April found that 11.5 per cent of women who are pregnant report drinking alcohol. Almost 4 per cent report binge drinking — defined as four or more drinks on any occasion — in the last month. Given that women may be ashamed to acknowledge this, the true numbers may be higher.
To combat this, 43 states have enacted policies. These can be affirmative measures, like giving pregnant women priority for substance-abuse treatment, or punitive ones, like defining drinking alcohol during pregnancy as child abuse or neglect.
Proponents of such policies believe that they are making things better, especially for children. A recent study suggests they are wrong.
Researchers gathered birth certificate data for more than 155 million live births from 1972 to 2015. The researchers were interested in how many children were born at a low birth weight or prematurely. They compared the rates of these undesirable outcomes in times and places when alcohol-pregnancy policies did and did not exist. They controlled for a number of demographic and related factors, including those known to be associated with poorer birth outcomes, like poverty and cigarette smoking.
They found that policies that defined alcohol use during pregnancy as child abuse or neglect were associated with an increase of more than 12,000 preterm births. The cost of these were more than US$580 million in the first year of life. Policies mandating warning signs where alcohol was sold were associated with an increase of more than 7,000 babies born at low birth weight, at a cost of more than US$150 million.
A previous study looking at how these policies affected women's drinking found mixed results. States with punitive policies had more drinking, not less. Overall, neither type of policy seemed to be associated with lower levels of drinking.
It is possible that states that already had more drinking might have put such policies in place in response to it. But the research methods used accounted for this, and state-level data on drinking and the prevalence of fetal alcohol spectrum disorders were not available when most of the policies were enacted, making it hard to believe that the relative levels of problems were what spurred policymakers to act.
Sarah Roberts, an associate professor of obstetrics and gynaecology at the University of California, San Francisco, is an author of this study and other related work. Doctors have long discussed potential dangers with patients, one on one, with many benefits, she noted. But policies that punish women for or publicly warn them about harms from alcohol or drug use during pregnancy may lead to further harms by scaring women into forgoing prenatal care, she said.
Such policies may even convince them that talking with their physicians is not a good idea.
"Qualitative research finds that pregnant women who use drugs avoid prenatal care out of fear that, if their providers find out about their drug use, they will be reported to child protective services and lose their children," she said. "Our study found that child abuse/neglect policies led to decreased prenatal care use."
Other research confirms this hypothesis. Three years ago, researchers (including me) published the findings of a survey on legal requirements for drug testing in prenatal care. Although most women were tolerant of laws requiring screening of pregnant women, 21 per cent reported they would be offended if their doctors asked them about drug use as part of prenatal care, and 14 per cent said that mandatory testing would discourage prenatal care attendance.
It's that last bit that most concerns physicians. Avoiding medical care is not what we would like to see happen.
The goal of all of these policies is to improve the health not only of pregnant women, but also of the children they bear. Many people assume that if physicians simply provide more information — if women are just warned — things will improve. Without research, those assumptions are just unproven hopes.
Roberts had two suggestions for what might work better. The first: Start over and go through a rigorous process of engaging with women who drink during pregnancy to find out — from them — what would help. Second, stop treating pregnancy as a special case when it comes to alcohol.
"There is some evidence that general population alcohol policies — such as limiting where alcohol can be sold — are associated with improved birth outcomes," Roberts said. "This makes sense as research shows that the biggest predictor of drinking during pregnancy is drinking before pregnancy. Women don't start drinking during pregnancy; if they drink during pregnancy, it's usually a continuation of the way and the amount they were drinking prior to pregnancy."
It might be better to spend time making sure that women are connected to the health care system in general, and that they enter pregnancy healthy — rather than focusing on the nine months of pregnancy as if that were the only time that mattered.
It's easy to stigmatise women who drink during pregnancy, with words and with policy. The goal, though, is healthier mothers and infants. To achieve that, policymakers may need to stop stigmatising and start over.
Written by: Aaron E. Carroll
© 2019 THE NEW YORK TIMES
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