The diagnosis of fetal alcohol syndrome was first established by Jones et al (1973), who described what ‘seems to be the first reported association between maternal alcoholism and aberrant morphogenesis in the offspring.’ They investigated eight children from three ethnic groups, finding ‘a similar pattern of craniofacial, limb and cardiovascular defects associated with prenatal-onset growth deficiency and developmental delay’ (Jones et al, 1973).
That was a medical diagnosis. However, demonstrating the difficulty of establishing a clear boundary between facts and values, Armstrong (1998) asserts that fetal alcohol syndrome also exemplifies the social construction of a clinical diagnosis. She argues that ‘[fetal alcohol syndrome] is a moral as well as a medical diagnosis, reflecting the broader cultural concerns of the era in which it was discovered’ (Armstrong, 1998). These cultural concerns included a heightened awareness of environmental threats to health, the development of fetal medicine and an emphasis on ‘the perfect child’.
It seems that fetal alcohol syndrome occupies a position in the moral landscape that appears to be freighted with difficulty. And it is into this problematic context that Bennett and Bowden (2022) pose the question ‘can routine screening for alcohol consumption in pregnancy be ethically and legally justified?’ They observe that in recent years, the publication of studies showing an association between alcohol exposure and low IQ has prompted media reports promoting the message that moderate drinking during pregnancy can adversely affect a child's IQ. Bennett and Bowden (2022) further cite evidence ‘that the prevalence of fetal alcohol syndrome disorders in the UK is significantly underestimated and there have been calls for urgent action to clarify and address this.’
Yet, while acknowledging the important fact that heavy drinking during pregnancy can lead to miscarriage and fetal alcohol syndrome, Bennett and Bowden (2022) comment that ‘the evidence regarding light or moderate drinking is not nearly as clear as the headlines might have us believe’. However, ‘Public Health England has stated that the alcohol intake of all women should be recorded throughout pregnancy…and that tools such as blood biomarkers and meconium testing should be researched in order to determine true prevalence rates of alcohol in pregnancy’ (Bennett and Bowden, 2022). Bennett and Bowden (2022) argue that such proposed enhanced screening undermines women's autonomy. They contend that there is no evidence that such screening will reduce fetal harm, ‘and there is a danger that undermining the autonomy of women and the trust relationship between women and healthcare professionals may even increase harm to future children.’ (Bennett and Bowden, 2022).
Given the ill-defined evidential relationship between light maternal alcohol consumption and fetal outcome, combined with conflicting professional advice that pregnant women may receive, Reynolds et al (2019) undertook a large epidemiological 8-year study (2010–2018) in Ireland to investigate the association between fetal growth and maternal alcohol behaviour before and during early pregnancy. They analysed the clinical and sociodemographic details of 68 925 women who delivered a baby weighing 500g or more. One third abstained from drinking alcohol before pregnancy, 98.4% reported abstinence at their first antenatal visit, only 1.2% reported light consumption (1–2 units/week), 0.4% reported moderate/heavy consumption (>3 units/week) and 0.3% reported binge drinking (>5 units in one sitting).
An important finding was that in the absence of persistent smoking or illicit drug abuse, there was no relationship between light alcohol consumption in early pregnancy and ‘aberrant fetal growth in the absence of persistent maternal smoking’ (Reynolds et al, 2019).
With a commendably high 98.4% of women abstaining once they knew they were pregnant, and a relatively low 0.3% reporting binge drinking, what are the implications of these findings from a public health perspective? Reynolds et al (2019) are clear that however well intended, it is important that reports ‘on the rate of alcohol consumption during pregnancy in Ireland are not unduly alarmist’, and they suggest that advising complete abstinence from alcohol from conception until after delivery may be impractical, especially as one third of all pregnancies in their study were unplanned.
Given the nuanced nature of the alcohol-in-pregnancy debate, some might argue that application of the ‘precautionary principle’ should favour complete abstinence. The precautionary principle derives from the German ‘Vorsorgeprinzip’ or ‘foresight principle’, where governmental foresight is needed to prevent environmental risks and dangers. It was first used in the text of the 1985 Vienna Convention for the Protection of the Ozone Layer but has spread beyond its environmental origins to areas such as public health.
But in the context of evidence-based medicine, how does a ‘better safe than sorry’ approach fit into a medical culture that is apparently dedicated to proven scientific methods of risk evaluation? As Reynolds et al (2019) indicate, if pure logic were followed, the precautionary principle could be extended to warning against the consumption of other beverages during pregnancy such as caffeinated and high-sugar drinks.
Perhaps a public health approach that prioritises strategies to help women refrain from binge drinking or heavy drinking of alcohol before, during and after pregnancy would confer more benefit than the promotion of blanket abstinence. The promotion of abstinence derives less from an assessment of available evidence and more from one that embraces the moralistic tenets identified by Armstrong (1998).