The National Institute for Health and Clinical Excellence (NICE) of the UK draft guidance is at odds with official guidance and has added confusion to the whole issue. In this week’s British Medical Journal (BMJ) two experts debate the topic.

The Individual Woman Should Decide
Pat O’Brien, Consultant Obstetrician, Institute for Women’s Health, London

Up to May 2007 the UK Department of Health recommended that a pregnant woman not exceed one or two alcohol units once or twice a week. The Department, as well as the BMA (British Medical Association), now say pregnant women should abstain from alcohol altogether.

O’Brien asks why this change if no new evidence has come to the fore. He explains that heavy alcohol intake during pregnancy brings with it a serious risk of fetal alcohol syndrome, a serious condition. However, no evidence exists that moderate alcohol consumption during pregnancy has any long-term detrimental effects.

O’Brien says that telling women to abstain completely is paternalistic as the decision should be made by the mother herself.

The advice has changed because, as it is, the recommendation is ambiguous – at the same time people are uncertain about what a unit of alcohol is. “If we in the medical and midwifery professions have failed to communicate clearly to women the meaning of safe limits, then we need to put this right – not take the easy option (for us) and ban alcohol completely,” writes O’Brien.

In 1981 the US Surgeon General advised complete avoidance of alcohol during pregnancy, explains O’Brien. However, the incidence of regular alcohol drinking during pregnancy in the USA rose from 0.9% in 1991 to 3.5% in 1999. If the advice is to abstain completely it becomes more difficult to collect data and know exactly what is going on. Women are less likely to admit to drinking during pregnancy if they know total abstinence is the only advised option.

Obviously, faced with the current evidence, many women will chose to abstain completely anyway. However, that choice should be freely made by each individual mother-to-be, concludes O’Brien.

Tell Mothers-to-Be To Abstain
Vivienne Nathanson, Director of Professional Activities at the British Medical Association

Nathanson believes the safest thing to do is tell pregnant women and those planning to become pregnant to avoid alcohol altogether. Alcohol can have a negative effect on the reproductive process in several different ways – it can cause:

— miscarriage
— preterm deliveries
— stillbirth
— low birth weight infants
— fetal alcohol syndrome
— neonatal developmental problems

Nathanson explains that some evidence is surfacing that there may even be risks if a pregnant mother consumes alcohol in moderation. Studies are indicating that two to five units of alcohol a week might delay the development of the fetus’s nervous system – and effect which could be permanent. Another large recent study found that occasional low to moderate drinking during the first three months of pregnancy may undermine the infant’s future mental health.

Guidelines, as they stand, can be interpreted in many different ways, argues Nathanson. If people do not clearly understand what ‘standard drinks’ or ‘units’ are exactly, moderate drinking for one person could be heavy drinking for another. How many women continue to drink in their pre-pregnancy fashion during their first trimester before they realize they are pregnant?

As the present guidelines are confusing, likely to be interpreted in many different ways, the most sensible step is to advise the pregnant woman, as well as the woman who plans to become pregnant, not to drink at all, concludes Nathanson.

“Is it all right for women to drink small amounts of alcohol in pregnancy? No”
Vivienne Nathanson
BMJ 2007;335:857 (27 October), doi:10.1136/bmj.39356.489340.AD
Click here to read the first 150 words online

“Is it all right for women to drink small amounts of alcohol in pregnancy? Yes”
Pat O’Brien
BMJ 2007;335:856 (27 October), doi:10.1136/bmj.39371.381308.AD
Click here to read the first 150 words online

Written by: Christian Nordqvist