By Rachel Arkell and Ellie Lee.
Since the 1980s, some have suggested using meconium (an infant’s first faeces) as a source of biomarkers for establishing Prenatal Alcohol Exposure (PAE) – a term that has come into use to describe the identification of alcohol consumption by a pregnant woman. More recently, it has been presented as the front-runner in the development of alcohol screening in pregnancy, on the grounds it is non-invasive in sample collection and considered a ‘long-term marker’ of alcohol intake (as meconium begins to form at around 12 weeks gestation, it offers a ‘direct reflection’ of maternal consumption during the 2nd and 3rd trimesters).
Meconium screening is referenced in the new UK policy framework about Fetal Alcohol Spectrum Disorder (FASD), in discussion of its prevention and in proposals for a research agenda including new ‘feasibility studies’ into its use. The UK Chief Medical Officers’ 2016 guidelines on ‘low risk drinking’ promoted a purely ‘abstinence-only’ public health message and advice to those who are/could become pregnant; the new policy framework on FASD, however, has shifted the focus to collecting information to facilitate future diagnoses of FASD and discussion of meconium screening is part of this shift.
As Bennett and Bowden note in their recent JME Blog and article, and as we have discussed elsewhere, the emphasis is now on gaining information about women, rather than for women. This shift is apparent in the text of the set of mutually enforcing policy documents that make up the new policy framework (these documents include the Scottish Intercollegiate Guidelines Network (SIGN) Guidance 156 (2019), Public Health England’s (PHE) Maternity High Impact Area policy document, ‘Reducing the incidence of harms caused by alcohol in pregnancy’ (2020), and NICE’s recently published Quality Standards on FASD (2022). All emphasise the need to screen all pregnant women, regardless of whether the level of consumption is viewed as ‘risky’. Proposals for meconium screening further the view that screening is the only correct option for dealing with fetal alcohol exposure in pregnancy, and will contribute to improving maternal and child health. Yet, as the policy documents themselves highlight, this thinking around routine screening is not currently supported by available evidence and is contestable. So why is meconium screening discussed in the way it is, as a possible answer to the question of how best to elicit reliable information on alcohol consumption during pregnancy? And what are the problems with this answer?
Proposals for using biotechnology in this area of antenatal care, even when there is no good evidence for their benefits are, firstly, not surprising when placed in the context of measures already taken that reflect institutional mistrust of those self-reporting. Similar conversations about evidence and its absence were raised, and quickly ignored, when carbon-monoxide monitoring in pregnancy was first proposed to assess maternal smoking status throughout pregnancy. Meconium screening can be best understood as supported because it is already the case that women are considered unreliable in regard to information they may disclose to healthcare professionals, and thus, the idea that measures are needed to obtain accurate ‘objectively’ has currency.
This underpinning of mistrust in the proposed use of meconium as an ‘objective measure’ is itself one part of the reasons why this form of screening cannot be ethically, legally or socially justified, however. Indeed, its proposed use, as a potential replacement for self-reporting, could do more harm than good, through jeopardising meaningful attempts to form open and trusting relationships between healthcare practitioners (HCPs) and pregnant women. In our contribution to JME, we argue this objection runs alongside others. One is that meconium screening fails to meet the definition of a typical screening measure, owing to the inherent limitations of the screen, meaning it fails to serve as a tool for harm prevention. Another is absence of proper attention to patient consent and autonomy, set aside through the policy push towards ‘routinisation’.
It is a problem that the policy framework for FASD was accompanied by so little debate and scrutiny as part of its development. There is, however, a growing body of literature that asks questions of attempts to regulate behaviour during pregnancy. Bowden and Bennett have keenly noted the lack of critical engagement about the interests and rights of women in the discussion. Further, the Responses to Alcohol and Pregnancy Policy (RAPP) Project is seeking to explore the views of midwives on this expansion of their professional duties. If the recent proposal reversal with the NICE Quality Standard, which dropped the proposal to automatically transfer maternal alcohol information to children’s health records can teach us anything, it is that critical engagement and debate as part of policymaking is necessary to safeguard the privacy interests and rights of pregnant women. Much more open and extensive debate about meconium screening (and other forms of biomedical screening) is essential.
Authors: Rachel Arkell¹ and Ellie Lee²
Affiliations: ¹ Centre for Reproductive Research & Communication, British Pregnancy Advisory Service, Stratford-Upon-Avon, UK. ² School of Social Policy, Sociology and Social Research, University of Kent, Canterbury, UK.
Competing Interests: The British Pregnancy Advisory Service was a registered stakeholder for the NICE Consultation on their Quality Standards on FASD and submitted consultation responses.
Social medical accounts of post authors: @R_Arkell