Reason, July, 1990, pp. 41-42
The New Thalidomide
A growing number of pregnant women in the United States avoid alcohol as if it were thalidomide. The pronouncements of government officials, journalists, and other professional alarmists have convinced them that drinking any amount of alcohol during pregnancy endangers the fetus. This new conventional wisdom is embodied in the federal warning that now appears on every bottle of wine, beer, and liquor manufactured for sale in this country: "According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects."
The horrible effects of fetal alcohol syndrome which include mental retardation, cardiac defects, and facial deformities were publicized throughout the 1980s. More recently, The Broken Cord, Michael Dorris's account of his experiences in raising an adopted Native American child suffering from FAS, has renewed the storm of anxiety about alcohol consumption during pregnancy. Dorris's book warns people that the danger of drinking by pregnant women has been vastly underestimated. The news media have been eager to amplify that view.
The success of the campaign against drinking during pregnancy demonstrates that any attacks on alcohol, no matter how far-fetched, misleading, or counterproductive, are nowadays immune from criticism. By blurring important distinctions, reports on FAS have generated needless worry among occasional or moderate drinkers while distracting attention from the real problems of prenatal care.
People have long recognized that heavy alcohol consumption is a risky behavior for pregnant women. But U.S. researchers first used the term fetal alcohol syndrome in the early 1970s to describe severe abnormalities in the newborn children of alcoholic mothers, including brain damage and readily observable physical deformities.
Such children are quite rare, however, even among heavy drinkers. In their 1984 book Alcohol and the Fetus, based on a comprehensive survey of the research, Dr. Henry Rosett and Lyn Weiner of Boston University reported that studies find FAS occurs in only 2 percent to 10 percent of children born to alcohol abusers. Furthermore, they reported that in every one of the 400 FAS cases described in the scientific literature, the mother "was a chronic alcoholic who drank heavily during pregnancy."
The infrequency of FAS has prompted researchers to expand their focus beyond the severe birth defects sometimes caused by heavy drinking. Hence "fetal alcohol effect," which refers to more-subtle impairment that might ordinarily escape attention. Closely tied to the rather vague notion of fetal alcohol effect is the suggestion that light or moderate drinking might also be dangerous. Warnings about FAS, fetal alcohol effect, and the alleged risks of any drinking during pregnancy get tossed together in the news media.
A February article by Dr. Elisabeth Rosenthal in The New York Times Magazine, "When a Pregnant Woman Drinks," begins with a horrific tale of an FAS victim. In this case, not only did the 8-year-old girl have FAS, but so did her siblings and her mother. Immediately following this extreme example, the article describes how Dr. Claire Coles, an FAS expert, has begun to "see the survivors of drinking pregnancies everywhere." For example, upon visiting a reform school Coles observed, "My God, half these kids look alcohol affected."
The bait-and-switch juxtaposition of Coles's observation with the severe FAS case creates the false impression that such alcohol-related birth defects are common. Alcohol affected, the term used by Coles, is generally applied to infants who have problems that fall short of FAS, such as irritability, attention deficits, hyperactivity, or developmental delays. The condition cannot be discerned simply by looking at a child. But for those who see fetal alcohol effect "everywhere," even criminal behavior may be the result of a mother's drinking. (Attorneys representing condemned California murderer Robert Alton Harris offered such an argument.)
Increasingly, problems such as delinquency and learning disabilities are being attributed to maternal drinking. Combined with warnings about moderate alcohol consumption, this tendency is likely to cause irrational guilt among many parents. The mother of a child who gets into trouble or has difficulty in school will start to wonder if this has anything to do with the wine she occasionally drank during her pregnancy.
Weiner, co-author of Alcohol and the Fetus, has described the anxiety caused by exaggeration of the danger from drinking during pregnancy: "Women are worrying about wine vinegar in their salad dressing and getting hysterical about the risk of eating rum cake. and they think they need an abortion after they hear the scare stories."
What grounds, if any, are there for such alarm? Rosenthal's article is accompanied by a subhead that warns, "New Studies Show that Even Moderate Consumption Can Be Harmful to the Unborn Child." But the article cites only one study to support this claim: In 1988. a University of Pittsburgh researcher found "minor anomalies" in children of mothers who consumed less than one drink a day during pregnancy.
Rosenthal has latched onto one highly unusual finding in a sea of contradictory evidence, ignoring a host of studies that have found no effect from consumption of two drinks a day or less. In 1984 Rosett and Weiner concluded that "the recommendation that all women should abstain from drinking during pregnancy is not based on scientific evidence." The overwhelming majority of studies since then have also failed to find evidence that moderate drinking harms the fetus. In fact, Dr. Jack Mendelson, a distinguished alcohol researcher at Harvard Medical School, has declared, "It is possible that some doses of alcohol, low or moderate, may improve the probability for healthy pregnancies and healthy offspring."
Given the rush to condemn any drinking during pregnancy despite the dearth of research evidence to support such a policy, you might guess that fetal alcohol effect, if not FAS itself, is a widespread phenomenon. But the Centers for Disease Control estimate that 8,000 "alcohol-damaged babies" are born each year, which works out to a rate of 2.7 for every 1,000 live births (0.27 percent).
Yet New York Times health columnist Jane Brody offered a much higher figure in 1986, when she announced, "An estimated 50,000 babies born last year suffered from prenatal alcohol exposure." (Brody, by the way, does not think it's enough merely to abstain from alcohol during pregnancy: "Even drinking before pregnancy [as little as one drink a day] may have an untoward result," she reported.)
Rosenthal does not offer her own estimate, but she says the CDC figure seems low, apparently because "on some Indian reservations, 25 percent of all children are reportedly afflicted." But as she later notes, "The CDC data show that the syndrome is 30 times more commonly reported in Native Americans than it is in whites, and six times more common in blacks." These figures indicate that alcohol-related damage among babies of white, middle-class women is actually less common than 2.7 cases per 1,000, since all groups are averaged together in producing the overall rate.
Indeed, it's not clear what the middle-class women who read the Times can learn from the experience of grossly dysfunctional families such as the one described at the beginning of Rosenthal's article or from reports about Native American children such as the mentally retarded boy in The Broken Cord. For one thing, styles of drinking vary widely across racial and socioeconomic groups.
White, middle-class women are more likely to drink than black women (and low-income women generally), but they tend to drink moderately. Black women are more likely to abstain, but those who don't are more likely to drink heavily. The fact that FAS rates are much higher among low-income minorities therefore contradicts the hypothesis that moderate drinking during pregnancy is damaging and that higher rates of abstinence would reduce FAS.
And a 1982 study by Boston University researcher Ralph Hingson suggests that other factors in the lives of poor, ghetto-dwelling women contribute to birth defects that have been ascribed solely to alcohol. After studying a sample of 1,700 women in Boston City Hospital, Hingson concluded that "neither level of drinking prior to pregnancy nor during pregnancy was significantly related to infant growth measures, congenital abnormality, or [other] features compatible with fetal alcohol syndrome."
Rather, a combination of factors-including smoking, malnutrition, and poor health care seems to be responsible for low birth weight and other problems often attributed to drinking. "The results underline the difficulty in isolating and proclaiming single factors as the cause of abnormal fetal development," Hingson and his colleagues wrote.
So the crusade against drinking during pregnancy is misdirected in several ways. It focuses on moderate rather than heavy drinking, on middle-class rather than low-income mothers, and on alcohol consumption rather than the set of behaviors that increases the risk of birth defects. The women most likely to give birth to damaged babies the ones who abuse alcohol and drugs, smoke, and neglect their health are not affected by messages tailored to the middle class.
The error in strategy is especially troubling given the nation's relatively poor performance in prenatal care. The number of birth defects in the United States has doubled in the last 25 years. While the U.S. neonatal death rate dropped in the 1980s, it still compares unfavorably with those of European nations, Japan, Australia, Singapore, Bermuda, and even Guam. Shrill warnings about low levels of drinking during pregnancy may make health experts feel virtuous. but they won't improve those figures one bit. Developing comprehensive community programs for high-risk mothers would help, but this requires more than Sunday supplement alarmism.