Wine and Pregnancy: Lies that Women Are Told

NOFAS wrote a response to an article, “Wine and Pregnancy: Lies that Women Are Told” that appeared on the Women Wine Critics Blog website.  This website, created by women wine producers, serves as an open forum for wine writers, winemakers, winery and vineyard owners, wine retailers, and wine critics to discuss any and all issues related to wine.  The article was written by Daniel Rogov, a well known European wine writer and author and the wine and restaurant critic for an Israeli daily newspaper and for the Israeli version of the International Herald Tribune.

NOFAS believes that this article sends a dangerous message to women—that it is safe to drink moderate amounts of alcohol during pregnancy.  The article presents very selective, inaccurate, and over-simplified information to reach this conclusion. As evidenced by some of the readers’ responses below, some women accept this type of misinformation as medical advice.

“As a woman, who just entered her second trimester and is dying for a glass of wine, thank you!!!!!”

“This is important news and a welcome relief for pregnant women across the country. I have been dying for a glass of wine, and like many women, I assumed it was forbidden. If the French women can do it, so can American women. Thank you for the truth!!!”

“Frankly, we have too many rules about food and alcohol that are to "safeguard ALL of us" from that small percentage who abuse or otherwise do the very wrong thing. We shouldn't live with wacky rules because of a few.”

“I work in an upscale Manhattan restaurant and it is very common that pregnant women diners order a glass of red, just one. I think the current is definitely changing in this direction.”

“So sad that this lie is told to women , there is no safe level of alcohol for pregnant women, studies continue to prove that alcohol crosses the placenta directly to the baby. Fetal alcohol is a permanent level of brain damage that the child must struggle with for the rest of their life. our adopted daughter was only exposed to wine during pregnancy, she looks cute on the outside, but spend some time with her and you understand that something is missing. She is 6 yr old in body, cognitive 2-3 yr on a good brain day.

Is the social drink that important to affect a child’s developing body?? My adopted daughter thinks not.!!”

“This is ridiculous. Yes, it is true. No one knows how much alcohol is too much during pregnancy, but why encourage alcoholics to continue drinking. Damage can still be done. Why would anyone want to take that chance? I have custody of 2 FAS girls. I know first hand what can happen if a pregnant woman drinks.”

You can read the article online at: http://dovercanyon.typepad.com/women_wine_critics_board/2006/01/wine_and_pregna.html

The NOFAS Response

The medical and scientific literature overwhelmingly supports the hypothesis that there are risks of alcohol related brain damage from drinking low to moderate amounts of alcohol during pregnancy.  Based on these findings, NOFAS’ position is that there is no safe time, no safe amount, and no safe alcohol during pregnancy.

We would like to respond to four main fallacies presented in the article:

1. There is no evidence that moderate drinking during pregnancy can harm a fetus.

2. There is evidence that moderate drinking during pregnancy can be beneficial to a fetus.

3. Public health messages to abstain from alcohol use during pregnancy are an affront to women's right.

4. Alcohol is just one in a long list of potentially harmful exposures for a fetus.

1. There is no evidence that moderate drinking during pregnancy can harm a fetus.

Drinking during pregnancy has always been an issue of risk, not certain harm.  At present, it is impossible to determine who is at risk for producing an affected child. No universal threshold of safe alcohol use during pregnancy exists. Researchers and medical professionals are not able to determine a safe limit for alcohol consumption during pregnancy where they could state with certainty that there would be no effect on the fetus. (Health Council of the Netherlands)

To begin with we must clearly define what we mean by “moderate” and “risky” drinking.  Both terms can mean very different things to different people.  Over the last few years, the research community has consistently been revising downward the number of daily drinks they consider to constitute both moderate and risky drinking.

Your article seems to define light to moderate drinking as a daily glass of wine (i.e.7 drinks per week).  The CDC now defines this amount (7 or more drinks per week or 3 or more drinks on multiple occasions, or both) as a “significant” level of prenatal alcohol exposure and advises seeking a diagnosis of FAS. (CDC, 2004)  This threshold amount was established by their review of the body of evidence from published research studies.  The definition of risky (or binge) drinking for non pregnant women has even gone from 5 drinks in a day to 4. (NIAAA, 2005)

Numerous studies have shown that even low levels of alcohol during pregnancy can produce physical, cognitive, and behavioral deficits in children. These findings have led the US Surgeon General, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, U.S. Preventive Services Task Force and many other professional medical societies to promote total abstinence from alcohol during pregnancy.

Because of genetic variations, some women and fetuses will metabolize alcohol faster than others. Everyone’s physiology is different and no two pregnancies are the same. For example, a mother who drank heavily through all her pregnancies may have a child with severe effects while her other children show no measurable effect.  Conversely, some women who drank moderately have produced children who exhibit physical and cognitive impairments consistent with the effects of prenatal alcohol exposure.

Most of the harm caused by prenatal alcohol exposure is less visible and extreme than fetal alcohol syndrome (FAS.)  Few, if any, children born to women who drink one glass of wine per day will be mentally retarded (state developmental disability offices typically define mental retardation as having an IQ score under 70.) These children are far more likely to have diminished intellectual abilities and behavioral problems. Even the majority of persons with FAS are not mentally retarded though they have varying degrees of psychological and behavioral problems and often find it difficult to hold down a job and live independently as adults.

Fetal Alcohol Spectrum Disorders (FASD) is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects may include physical, mental, behavioral, and/or learning disabilities with possible lifelong implications. The exact numbers of people affected by FASD are unknown however some estimate that 10 out of 1,000 babies born have FASD. (May, P. & Gossage, J., 2001)

See footnote 1 for further statistical information.

NOFAS uses the Iceberg analogy to describe the proportion of persons affected by prenatal alcohol exposure.  The visible iceberg represents persons with the FAS, a diagnosable condition.  The vast majority of affected persons are represented by the portion of the iceberg that lies underwater.  They are the persons with a range of mental and physical problems and limitations, who do not have a diagnosable condition.

Another problem with stating that “one drink is safe” is that people frequently underestimate the amount of alcohol they consume.  Researchers define a “standard” glass of wine as 5 ounces; the social drink size is often larger, particularly for red wine.  One study conducted with women in health clinics found that, for most beverages, the difference between self-selected drink size and a standard size drink was significant, with the mean self-selected drink sizes ranging from 49% above the standard size (for beer) to 307% above the standard size (for spirits).  What this means is that many women who self define as moderate drinkers are, in fact, risky or binge drinkers. (Kaskutas LA & Graves K, 2001)

Numerous studies have found risks to the fetus from low to moderate drinking during pregnancy.  Please see Appendix A for a sampling of these studies.

Further research needs to be done to examine the effects of low to moderate drinking during pregnancy as well as research on the factors that make some women more vulnerable to alcohol’s effects during pregnancy. Until more is understood, NOFAS believes that when it comes to the lifelong wellbeing of a child, we should err on the side of caution.

2. There is evidence that moderate drinking during pregnancy can be beneficial to a fetus.

The section of the article on supposed health benefits during pregnancy contains statements from researchers and medical professionals but fails to back up their words with any citations to peer-reviewed literature on the topic.  Furthermore, the article states that Dr. Robert Sokol (a leading researcher on FAS) reported that light drinkers and not abstainers have the best chance of having a baby of optimal birth weight. When reached for comment, Dr. Sokol denied conducting research that yielded these results. He has appeared on television opposing a doctor who suggested that wine was beneficial during pregnancy and recommends abstinence from alcohol during pregnancy.  This is just but one more example of the article’s misinformation.

There is some evidence that moderate drinkers—men who have two or less drinks per day and women who have one or less drinks per day—are less likely to die from one form of heart disease than are people who do not drink any alcohol or who drink more. These benefits are seen in men over 40 and women over 60 (DHHS/USDA, 2005). However, there is no evidence that drinking during pregnancy can be beneficial to a fetus.

Unfortunately, yours is not the first claim of the supposed benefits of drinking during pregnancy.  Advice given in the1980s that alcohol helped with increased milk production and decreased risk for premature labor has also since been discredited by the medical community.

3. Public health messages to abstain from alcohol use during pregnancy are an affront to women's right.

Your argument is poorly disguised as a women’s rights issue.  This notion is preposterous and smacks of conspiracy theory.  This is not an issue of patriarchy and attempts to control women’s bodies.

The nation spends a great deal on FASD ranging from clinical research studies to the societal costs incurred by persons with FASD.  Fortunately, the vast majority of government efforts to address drinking during pregnancy are not punitive in nature and do provide some, albeit inadequate, funding.  For instance, relevant state statutes primarily provide for public awareness campaigns, priority access to substance abuse treatment, and case management services. The few pieces of punitive legislation introduced in state legislatures have rarely passed, and those that have passed have subsequently been overturned. Read more about state approaches to FASD at http://www.nofas.org/resource/State_Report.htm.

NOFAS does not support prosecuting women who drink alcohol during pregnancy. Past studies have shown that education and treatment are seven times more cost effective than arrest and prison for substance addiction.  We believe that public policy should focus on improved treatment options for those with a substance abuse dependency.

Aside from pregnant women, no one is “benefiting” from spreading the message of alcohol abstinence during pregnancy.  What would be the ulterior motives for spreading this message?

The argument that people should be free to make their own choices regarding behavior has been made to oppose virtually every public health initiative from mandatory seat belts, to helmets, to smoking in public places, etc.  The public, however, is showing it is not willing to foot the bill for irresponsible and costly behavior.

With all due respect to the wine writer and the political and cultural commentator cited in the article who suggest that it is safe for women to drink during pregnancy, we choose to place our trust and confidence in the medical and scientific community when it comes to this very important issue of a child’s lifelong health and wellbeing.

4. Alcohol is just one in a long list of potentially harmful exposures for a fetus.

True, there are many potential teratogens.  However, it is both the degree of harm caused by prenatal alcohol exposure and the pervasiveness of drinking during pregnancy that sets it apart from other risks. Drinking during pregnancy is also an issue of relative risk. In their report to Congress, the Institute of Medicine claimed, “Of all the substances of abuse (including cocaine, heroin, and marijuana), alcohol produces by far the most serious neurobehavioral effects in the fetus.” (Stratton et al, 1996.) If we cast the legality of the substance aside, it would be hard to imagine anyone supporting a pregnant woman’s decision to use moderate amounts of heroin, crack, or cocaine, despite the fact that there is no evidence demonstrating lasting effects on the child.

Alcohol is by far the mostly commonly used substance of abuse in this country.  The Substance Abuse and Mental Health Administration’s 2004 National Household Survey on Drug Use and Health showed that 50% of the population use alcohol.11.2 percent of pregnant women used alcohol and 4.5% of pregnant drank at risk levels for producing a child with FASD. (SAMHSA, 2005)

The majority of birth defects are of unknown origin.  Alcohol consumption is, however, one of the few we can control.  Unfortunately, over  40,000 pregnant women drink alcohol each year either because they do not know they are pregnant, they have addictions and are unable to stop, or have misinformation about the risks. Your article serves to perpetuate such misinformation.

Appendix A

Prenatal Alcohol Exposure Predicts Continued Deficits in Offspring Size at 14 Years of Age

Day, N. L.; Leech, S. L.; Richardson, G. A.; Cornelius, M. D.; Robles, N.; Larkby, C. Alcoholism: Clinical & Experimental Research. 2002 Oct;26(10):1584-1591.

This study examined the effects of prenatal alcohol exposure on growth at 14 years of age. Significant effects were seen in children whose mothers drank less than one drink per day.

Prenatal Alcohol Exposure and Childhood Behavior at Age 6 to 7 Years: I. Dose-Response Effect

Sood et al. Pediatrics 2001 Aug;108(2):34

This study found that maternal alcohol consumption, even at low levels such of one drink per week, was associated with adverse child behaviors at ages 6 and 7. The relationship between prenatal alcohol exposure and adverse childhood behavior outcome persisted after controlling for other factors associated with adverse behavioral outcomes. The authors concluded that these data suggest that no alcohol during pregnancy remains the best medical advice.

The Relationship between Alcohol Consumption During Pregnancy and Infant Birthweight. An Epidemiologic Study.

Virji, SK. Journal of the Scandinavian Association of Obstetricians and Gynaecologists1991;70(4-5):303-8.

This study examined the effect of social drinking and birth weight. Findings indicate that there is an adverse effect on the birth weight with moderate alcohol use during pregnancy.

Drinking Moderately in Pregnancy: Effects on Child Development

Jacobson, JL and Jacobson, SW.  Alcohol Research and Health 1999; 23(1):25-30.

This study found that children exposed to moderate levels of alcohol during pregnancy show growth deficits and intellectual and behavioral problems similar to, although less severe than, those found in children with fetal alcohol syndrome.

Dose-Dependent Effects of Prenatal Ethanol Exposure on Synaptic Plasticity and Learning in Mature Offspring

Savage et al. Alcoholism: Clinical & Experimental Research. 2002 Nov;26(11):1752-1758.

This study examined the question of whether lower maternal blood ethanol concentrations (BECs) could produce functional deficits in offspring.  The findings indicate that the threshold for eliciting subtle, yet significant learning deficits in offspring occurred when mothers drank the equivalent of 1 to 1.5 ounces of ethanol per day.

Alcohol and pregnancy: what is the level of risk?

Tat ha. Journal of Clinical and Experimental Toxicology 1990 Mar-Apr;10(2):105-14.

This article suggests that social type of alcohol consumption brings more discrete effects that often do not appear until much later. Low birth weight and mental retardation may be seen with the absorption of 15 ml of alcohol per day (1 beer or 1 glass of wine or 40 ml of liquor).

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1.  Fetal Alcohol Syndrome (FAS) is characterized by brain damage, facial deformities, and growth deficits. FAS is most typically caused by heavy drinking, defined as 3.5 or more drinks per day (Sokol et al 2002) or binge drinking during pregnancy (4 or more drinks in a row).  Approximately 0.5 – 2 per 1,000 babies born (2,000 - 12,000) are believed to have FAS. (CDC, 2002)  These figures would be significantly higher if cases of sudden infant death syndrome, miscarriage, and stillbirth were included.  Furthermore, the number of children affected adversely by in-utero exposure to alcohol is probably underestimated due to several barriers to surveillance and diagnosis.

There is no national surveillance plan that tracks FAS nor are there standardized reporting requirements. Birth defect cases are usually recorded at birth however FAS cases are often not diagnosed and/or misdiagnosed at birth due to the difficulty of making a diagnosis in newborns. Other barriers include the lack of medical biomarkers, lack of education and awareness among healthcare professionals, and the negative perceptions of FAS diagnosis. Also, some children might not be identified as having FAS until they reach school age, at which point CNS abnormalities and learning disabilities are recognized more easily. Diagnoses made at this age and documented in educational records are rarely considered in surveillance activities.  (CDC, 2002) 

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Bibliography

Centers for Disease Control and Prevention. Fetal Alcohol Syndrome --- Alaska, Arizona, Colorado, and New York, 1995—1997. MMWR May 24, 2002 / 51(20);433-5.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5120a2.htm

Centers for Disease Control and Prevention. Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis. 2004.

http://www.cdc.gov/ncbddd/fas/documents/FAS_guidelines_accessible.pdf

Health Council of the Netherlands. Risks Of Alcohol Consumption Related to Conception, Pregnancy and Breastfeeding. The Hague: Health Council of the Netherlands, 2005.

http://www.gr.nl/adviezen.php?ID=1171

Kaskutas, LA., and Graves, K. Pre-pregnancy drinking: How drink size affects risk assessment. Addiction 96:1199–1209, 2001.

May, P. and Gossage, J. Estimating the Prevalence of Fetal Alcohol Syndrome: A Summary.  National Institute on Alcohol Abuse and Alcoholism. 2001.

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