The Centers for Disease Control and Prevention (CDC) came under heavy criticism last week when it released new guidelines suggesting that any woman who might become pregnant should consider not drinking alcohol out of concern for their hypothetical fetus’ well-being. Had the CDC limited its advice to women who were already pregnant—or even those who were actively trying to become pregnant—it would have been likely seen as reasonable, based on existing research about the risks of alcohol during pregnancy. But the suggestion that the advice should apply to all women who are sexually active and not on birth control is overreaching and patronizing.
There are two public health issues that the CDC was evidently trying to address: the dangers of fetal alcohol spectrum disorders (FASDs) and the high number of unplanned pregnancies in this country. By not keeping them separate, the CDC effectively reduced all women to nothing more than fetus-vessels-in-waiting.
Experts believe that FASDs are widespread and under-diagnosed. Symptoms of FASDs range from mild to severe and include a variety of physical, emotional, behavioral, and learning problems. Research shows that exposure to alcohol in utero can cause structural or functional problems to the central nervous system, heart, brain, bones, and kidneys. It has been associated with higher incidents of behavior disorders, such as attention deficit/hyperactivity disorder and impaired impulse control, and learning disorders, such as difficulties with mathematics, language, memory, and problem solving.
There is no great way to measure whether it’s possible to drink just a little bit without exposing the developing fetus to any risk. We don’t do randomized controlled trials on pregnant women, for example, because it would be unethical to intentionally expose a developing fetus to any substance that might be harmful for the sake of research, and other factors such as genetics, nutrition, smoking, and prenatal care make every pregnancy different to begin with. Many studies have failed to find any negative outcomes from light drinking during pregnancy.
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Still, a report from the American Academy of Pediatrics released in October notes that drinking during the first trimester increases the odds of FASD by 12 times when compared to women who don’t drink at all. Drinking in the first and second trimester increases the odds 61 times compared to no alcohol, and drinking during all three trimesters increases the odds by 65 times. These are big risks, and the AAP concludes that simply “no amount of alcohol should be considered safe during pregnancy.”
With all that in mind, the logic behind the CDC’s advice seems simple enough. Ann Schuchat, the agency’s principal deputy director, explained to USA Today, “Alcohol can permanently harm a developing baby before a woman knows she is pregnant. About half of all pregnancies in the United States are unplanned, and even if planned, most women won’t know they are pregnant for the first month or so, when they might still be drinking. The risk is real. Why take the chance?”
But the advice the CDC released on its website is anything but simple: “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.” Remember, this is not referring to pregnant women, it’s talking about all sexually active women who might become pregnant.
Upon reading this, many on the Internet cringed. As Alexandra Petri pointed out for the Washington Post, the CDC released an infographic along with its report that outlined the risks of “drinking too much” for women. For pregnant women, according to the agency, these risks include fetal alcohol syndrome disorders, miscarriage, stillbirth, sudden infant death syndrome, and prematurity. For all women, the CDC continues, risks include “violence, sexually transmitted diseases, and unplanned pregnancy.”
If the CDC wanted to remind women of the dangers of FASDs, it should have stuck to pregnant women or those trying to become pregnant. You see, many pregnant people are accustomed to taking the advice of medical organizations, our doctors, and our friends and doing some personal risk-benefit analyses. Right before I sat down to write this article, I went to the medicine chest and washed down a few aspirin with an extra cup of coffee in an effort to stop my head from pounding. I was reminded of a time when I could not do that because while pregnant and breastfeeding, I was told to limit my caffeine intake and use nothing stronger than Tylenol. I also avoided deep-sea fish (because of mercury levels) and lunch meat (because of the possibility of listeria). And despite the horrifying heartburn I had pretty much every night I did not take the proton-pump inhibitor I had been on for a few years before pregnancy because it had not been tested enough to be considered safe.
I did, however, eat soft cheese. My doctor advised me not to because of fears of bacteria, but a friend in culinary school at the time along with the guy behind the counter at the Vinegar Factory assured me that all cheese sold in the United States is pasteurized. I believed them and indulged in some brie from time to time.
One friend, meanwhile, took ibuprofen during her pregnancy because her back was too painful to walk without it. Another suffered through a major sinus infection with no painkillers because even Tylenol made her nervous. Some drank a glass of wine every now and then, and others skipped booze entirely.
Medical advice to women changes frequently as science learns more. My mother smoked throughout her pregnancy with my sister because that was acceptable in 1970. By the time she was pregnant with me two years later she was told to cut out cigarettes, but late in the pregnancy, was ordered to drink one glass of alcohol a day to “quiet the baby.” Though that seems outrageous 40 years later, advice changed in the relatively short time between my two pregnancies as well. The second time around, I was allowed to take that proton-pump inhibitor, because it had been declared safer, but I was told to avoid peanut butter as a way to prevent an allergy in the baby.
Pregnant people are often used to reading and evaluating advice on what they can and can’t do. Tell them not to drink and many will not drink. Others may drink even less than they were planning to, and others may do whatever their doctor says; mine assured me that the occasional glass of red wine was fine.
Limiting the advice to this audience would have been a problem too, however, as it would have missed a large number of women who get pregnant each year. Why? Because, as the CDC noted, half of all pregnancies are unplanned, though not everyone decides to carry their pregnancies to term. And this was the real messaging challenge: The advice about not drinking starts from day one of pregnancy when most women, especially those who aren’t expecting to become pregnant, are unaware of their new condition. So the CDC’s message of risk elimination is understandable. There is another way to confront that, though: addressing the importance of contraception, recognizing that it is currently not equally available for all women, and advising policymakers to make it easier to access birth control.
This is how the CDC miscalculated. Telling all women who are not pregnant and not using birth control to stop drinking is an absurd strategy. It is unrealistic and undermines the real public health risk the CDC is attempting to highlight. And accusing sexually active women who are not using birth control of damaging a developing baby that they may never conceive or might not carry to term if they do is patronizing and demeaning to women. (Not to mention the fact that not all sexually active women are at risk of unintended pregnancy—women who only have sex with women, for example, are in the clear.)
Tell women who are or are planning to get pregnant that the best medical advice of the day is not to drink any alcohol. For the trickier bunch—those who aren’t trying to get pregnant but could, remind them that half of all pregnancies are unplanned. Point out the benefits of planned pregnancy, which do include avoiding unintentionally exposing a developing fetus to alcohol. If they do want to avoid pregnancy, suggest IUDs and implants, which prevent it for a minimum of three years without any effort on the part of the user. Work on making contraception more readily available and less expensive.
But don’t treat all women like pregnancies waiting to happen, don’t assume that everyone is going to get pregnant someday, don’t assume that everyone who does get pregnant will carry the fetus to term, and don’t tell them that they simply can’t drink during their fertile years.