I feel a lot of what I've been doing recently has been pretty reactive. 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 not that long ago. This should be relatively straightforward, and yet it wasn't. That's the topic of this week's Healthcare Triage.

(Intro)

It's pretty widely believed that if a fetus is exposed to alcohol while in utero, it has a greater than zero chance of developing foetal alcohol syndrome. That's the collection of issues which include low birth weight and growth, and problems with organs such as the heart, kidney and brain. Kids with foetal alcohol syndrome can also 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 makes preventing this difficult. No one knows how much alcohol is needed in utero for a child to develop foetal alcohol syndrome. 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' 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 felt like women in the United States took this 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 while they're pregnant.

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 3% report binge drinking in the last month. Pregnant women most likely to drink are 35 to 44 years old, not married, and are college graduates. Those who report binge drinking in the last month say they did so between four and five times that month. More even than non-pregnant women.

I'm a rate-limiting step guy. If we want to prevent foetal alcohol syndrome, starting with the women who binge drink 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.

Let's quote from their report: "More than three 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 four to six weeks into the pregnancy. This means a woman might be drinking and exposing her developing baby to alcohol without knowing it. Alcohol screening and counselling 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, and I'm quoting again; "Why take the risk?" And it's part of the 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 in to 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 increases the risk of death to children. You need to weigh risks and benefits.

What's the prevalence of foetal alcohol syndrome? Even the CDC can't decide. In their data and statistics section, they say that some records can identify 0.2 to 1.5 infants with foetal alcohol syndrome for every 1,000 births. A more recent study found 0.3 out of 1,000 kids seven to nine years of age has foetal alcohol syndrome. Other in-person assessments found that six to nine per thousand kids might have foetal alcohol syndrome. But their new infographic proclaims, and I'm quoting; "up to one in 20 US school children may have foetal alcohol syndrome". Huh? Moreover, their other infographic says that women who drink too much have a higher risk of injuries and violence, sexually transmitted diseases, and unintended pregnancy. That has caused the blogosphere to lose its shit, and I can't blame them.

The alcohol doesn't cause these things and the CDC knows it. It's an association, and it's part of a pathway, but the way they talked about it is being interpreted as victim blaming. Especially since they're only talking about it to women. 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 things you'll regret. For that matter, why is this part of the foetal alcohol syndrome discussion at all? It comes across as fear mongering about alcohol, period. And if we go this route, why not just go back to prohibition, and that's the way we could prevent foetal alcohol syndrome.

I get what the CDC is trying to do 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 foetal alcohol syndrome, we should try and limit the number of women who drink thinking they're not pregnant and they are. True. So women should think carefully about being sexually active without birth control when they're still drinking alcohol in their life.

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 foetal alcohol syndrome and get the most bang for out 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 if alcohol is safe at any time or how much might be safe. Then 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.

Healthcare Triage is supported in part by viewers like you through patreon.com, a service that allows you to support the show through a monthly donation. Your support makes this show bigger and better. We'd especially like to thank our research associate Joe Sevits, give a special shout-out to Jonathon Dunn, and thank our surgeon admiral, Sam. Thanks Joe and Jon! Thanks Sam! More information can be found at patreon.com/healthcaretriage.