By Rebecca Bennett and Catherine Bowden
Since a link was established between alcohol consumption in pregnancy and Fetal Alcohol Spectrum Disorder (FASD) there have been attempts to reduce women’s alcohol consumption during pregnancy.
As a result, many jurisdictions, including the UK have taken what is called ‘abstinence only approach’ as the basis for all policies on alcohol consumption in pregnancy, where women are advised that alcohol should be avoided completely not just during pregnancy but at any time that pregnancy may be a possibility.
Our recent paper considers further proposals to increase screening of pregnant women for alcohol consumption in order to prevent instances of FASD. The proposals we focus on are:
- Scottish Intercollegiate Guidelines Network (SIGN) Guideline 156, 2019 recommending that screening questionnaires and associated use of blood biomarkers should be considered to identify alcohol exposure in pregnancy.
- National Institute for Health and Care Excellence (NICE) Draft Quality Standard, 2020 recommending that pregnant women should have information on their alcohol consumption recorded throughout their pregnancy and transferred to the child’s health records. The final version has since been published, dropping the proposal to transfer the information to the child’s records.
- Public Health England (PHE) Maternity high impact area: Reducing the incidence of harms caused by alcohol in pregnancy, 2020 suggesting 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.
However, there are several problems with these proposals including:
- Little evidence that light to moderate drinking is harmful with some studies actually showing it is associated with better outcomes.
- Evidence is that only very small numbers of pregnant women (perhaps as low as around 2.9%) drink more than one alcohol unit a week.
- Even those arguing for extended screening and use of blood biomarkers accept that there is “…no evidence was identified which directly links a maternal history that has involved alcohol use to improved rates of diagnosis and better outcomes for a woman or her children.”
- There is a real danger that the extension of screening will be counterproductive with this added level of surveillance having the potential to discourage women most at need to support from engaging with antenatal services.
Despite these issues, those proposing this change of approach may still insist that the chance that we might prevent fetal harm in this very small minority of pregnant women who do drink heavily is enough to justify, what they might argue is a minor infringement of autonomy.
But is this really a minor infringement of autonomy?
Abstinence policies are opted for based on the concern that women might be confused by an accurate account of the risks involved, that is, that there is little evidence to support any link between low and moderate drinking and FASD. Thus, the detail of the evidence is simplified to the headline that even small amounts of alcohol consumption are a risk to your future child.
If we couple deception around the evidence here with the fact that routine screening will be difficult to refuse, there is a level of coercion here that seems difficult to justify, particularly to identify information that these women are already in possession of – they already know how much they are drinking.
Gaining information about women rather than for women?
It is likely that any under-reporting of alcohol consumption during pregnancy is a symptom of the lack of trust and fear of judgment that pregnant women feel and extending screening in pregnancy is likely to contribute to this rather than alleviate it. If we want to improve outcomes for mothers and their babies, the obvious solution appears to be to build the relationship of trust in antenatal care, making it easier for women to report their alcohol consumption as well as other key issues such as domestic abuse. Midwives want to give personalised, supportive care through a relationship of trust, and the increased focus on routine screening appears to run counter to this. This is something currently being investigated by the Responses to Alcohol and Pregnancy Policy Project.
There are many situations in healthcare in which individuals are asked about their alcohol intake. We know that individuals who are not pregnant tend to under-report their alcohol intake. However, the appetite for developing sustained routine screening to detect low levels of alcohol consumption seems to be limited to antenatal care. Why are pregnant women targeted in this way if there is little or no benefit to their future children in detecting low levels of drinking during pregnancy? There are too many temptations to moralise about the behaviour of pregnant women but if we want to treat pregnant women differently when it comes to screening for alcohol consumption then we need to have strong justification for this, and this is simply not here in this case.
Paper title: Can routine screening for alcohol consumption in pregnancy be ethically and legally justified? [OPEN ACCESS]
Authors: Professor Rebecca Bennett and Mrs Catherine Bowden.
Affiliations: Department of Law, School of Social Sciences, University of Manchester, United Kingdom.
Competing interests: None