In search of a better conversation about alcohol and pregnancy

Part 2 of 3

SPONSORED: The tidal wave begins to crest as soon as that second blue line appears on the home pregnancy test.

It starts with books, articles and online forums. Then sisters, mothers, aunts and friends start to weigh in, followed by coworkers and colleagues. Before long, strangers on the street begin stopping you to tell you what you should and shouldn’t be doing.

From prescription medications to coffee, soft-serve ice cream to soft cheeses, lunch meat, cantaloupe, herbal teas, exercise, skincare products, sweeteners and more, pregnant parents today are drinking from a firehose when it comes to advice about what to eat or not eat, do or not do, avoid or embrace.

The constant stream of unsolicited advice can understandably put new parents on the defensive.

“Guess what?” one ScaryMommy contributor writes in a post titled “Don’t Judge Me For Having That Glass of Wine While Pregnant.” “I’m a full-grown adult with an advanced degree in motherhood. I think I can handle eating or drinking whatever I want without the public rubbernecking and making sanctimonious commentary on it.”

That sentiment probably feels relatable to anyone who’s been pregnant and encountered a person who feels entitled to criticize what they’re eating, doing or buying. But drinking alcohol during pregnancy isn’t like ordering a milkshake or a cup of coffee. Here’s why.

Understanding and assessing risk

Some pregnancy advice is based in science. Some of it isn’t. And much of it is wildly misconstrued or misunderstood.

“We focus on ‘What kind of cheese you eat?’ or ‘Did you have one cup of coffee or two?’ and there’s no real evidence for that,” said Dr. Stephanie Eklund, an Anchorage OB/GYN. “But it’s dramatized and spread like wildfire.”

Take cantaloupe, for example. Some people have the impression that it’s dangerous in pregnancy. But dig a little deeper and you’ll learn that those concerns about cantaloupe stem from a single listeria outbreak in 2011 that sickened 147 people, killed 33, and caused one woman to miscarry. Cantaloupe itself is no more dangerous to a pregnancy than any other raw fruit or vegetable. (Listeria, which kills about 260 people in the U.S. each year, is at the root of many pregnancy warnings, including lunch meat, soft cheeses, and ice cream.)

With alcohol, on the other hand, the full picture of the risk is still developing. Fetal alcohol syndrome was identified in 1973, and it became well known following a 1981 Surgeon General’s warning advising pregnant women to stop drinking. (At the time, the founding director of the National Institute on Alcohol Abuse and Alcoholism called the warning “overkill”; today, the Institute advises total abstinence from alcohol during pregnancy.) Now it’s estimated that as many as 1 in 20 American children are affected by fetal alcohol spectrum disorders, including -- but not limited to -- FAS.

The wheels of public health research tend to turn slowly, said Susan Astley Hemingway, a professor of epidemiology and pediatrics at the University of Washington and director of the Washington State FAS Diagnostic and Prevention Network. It wasn’t until the 1990s that public health efforts to screen, diagnose and prevent FASD began, supported by agencies like the Centers for Disease Control.

Fetal alcohol spectrum disorders as a field of study are still relatively young, and reliable answers are hard to find in part because the controlled, double-blind study design ideally used for health research would require deliberately exposing fetuses to alcohol -- an experiment no organization would ever approve. It’s also difficult to disprove the potential for harm, especially when new research indicates that there are other factors at play, including genetics.

What is known today is that alcohol is a teratogen that has the potential to cause harm -- mild or severe -- at any stage of pregnancy, and doctors don’t have enough information to say whether there is a safe dose of that teratogen.

Hence the public health message that’s a simple statement of fact: There is no amount of alcohol known to be safe during pregnancy, so it’s best not to drink at all.

“I think it’s meant to be a diplomatic way of saying we don’t know what ‘moderate’ or ‘enough’ or ‘safe’ drinking is during pregnancy, and that’s probably because there’s not really any safe amount or safe time,” Eklund said. “I think it’s a little bit confusing, though, when you hear it and you’re not a medical person.”

And in a world full of confusing and conflicting pregnancy messages, where the phrase “Can I eat cream cheese while pregnant?” yields 14 million Google results, some parents are pushing back against any kind of blanket restriction in pregnancy. Drinking while pregnant is on the rise in the U.S., particularly among college-educated women in their 30s and 40s.

“How do you share with the general population -- being a mix of highly educated women, less educated women, and women who are suffering from alcoholism?” Astley Hemingway said. “Public health messages need to be succinct, accurate and resonate with the full spectrum of women.”

Finding better ways to talk to patients

That’s where providers come in, says Dr. Elizaeth Barlet. Barlet is the FASD Champion for the American College of Obstetricians and Gynecologists and chair of Women’s and Children’s Services for Mercy Joplin Obstetrics, Gynecology and Women’s Health in Joplin, Missouri.

“As OB/GYNs, we have to reach patients in a variety of ways,” Barlet said. “Some patients respond better to straightforward facts and statistics, while others prefer real-life examples of how something can affect their pregnancy.”

But even obstetricians may differ in their advice about alcohol use during pregnancy, something Eklund says is part of the problem.

“The people that should be listening are us, the providers,” she said. “If we (sent) a consistent message, that would be the first step.”

Recent research in Australia found that the use of alcohol during pregnancy is often influenced by conflicting social and emotional factors -- like not wanting to miss out on celebratory toasts or feeling anxious about what others will think -- suggesting that it’s important that health care providers equip their patients with reliable information about the chemical nature of alcohol as a teratogen.

Eklund says one of the most valuable tools at her disposal is a developmental chart that shows a fetus’s growth alongside the systems that alcohol has the potential to affect at any point in a pregnancy. It helps focus the conversation from a vague “it’s bad for the baby” to the potential for damage to specific parts of the body.

“A lot of providers don’t see it that cut and dried; it’s kind of a nebulous ‘It’s probably not good for you -- don’t do it that much,’” Eklund said. With the chart, “It’s like, ‘If you drink in your sixth week, this is what’s going to be affected.’”

Experts say health care providers should also be able to help patients sort through what they hear from friends, family, books and websites to make sure they’re getting the best information and asking the right questions.

“If you read something on the Internet or social media, be sure to run that past your OB/GYN to confirm that the information is accurate and safe for you and your baby,” Barlet said.

Overcoming fears & opening up

Before that dialog can happen, a patient has to be open with their health care provider -- and that can be intimidating when it comes to talking about alcohol.

“One of our whole challenges is how do we shift the stigma around alcohol and pregnancy?” said Marilyn Pierce-Bulger, an Anchorage nurse practitioner who specializes in diagnosing FASDs. “Because stigma is getting in the way of women disclosing and providers asking.”

Women drink more than they used to, and they’re less likely to get help if their drinking becomes a problem. But all too often, Pierce-Bulger said, there’s a reluctance among pregnant women to disclose any alcohol use. Patients don’t talk about it because they’re afraid of being judged, and doctors consequently may not realize how common it is.

“I’ve had providers say “Well, I don’t have those women in my practice,’” Pierce-Bulger said. “I’m sorry, but yes, you do. It’s not just ‘those women.’”

One thing parents may be reluctant to discuss is exposure to alcohol early in pregnancy. About half of all pregnancies are unplanned, and messages about drinking in early pregnancy can seem conflicting -- you should quit drinking if you might be pregnant, but you shouldn’t panic if you drank before you knew. Exposure early in pregnancy can cause problems, but Astley Hemingway said it comes down to understanding the “continuum of risk.”

“When we say it’s not safe to drink even a little bit during the first part of pregnancy, we’re talking about a risk,” she said. “The flip side is, if you’ve already done that drinking and now you’re frightened, I can emphasize that the risk is only 5 percent. There’s a higher chance that nothing’s going to happen, but it’s not zero.”

It’s the kind of reassurance and support an OB or midwife can only provide if the patient is willing to open up and share honestly.

“No matter what the issue, it’s important for patients to be completely honest with their medical provider,” Barlet said. “Your physician isn’t judging you for your lifestyle but does need to know all the facts to provide the best care for you and your baby.”

Read Part 1: ‘He looks so normal’: When it comes to FASDs, there’s no such thing as predictability

Read Part 3: Living with FASD: ‘I’m going to have this for the rest of my life’

It is never too late to stop drinking. Because brain growth takes place throughout pregnancy, the sooner you stop drinking the safer it will be for you and your baby. If you’ve been drinking while pregnant, stop immediately and talk to your medical provider. If you are unable to stop, your medical provider can refer you to resources for help. This series is sponsored by LetsTalkFASDak, an FASD prevention initiative of the State of Alaska administered through the Alaska Mental Health Trust Authority. Learn more about alcohol, pregnancy, and what you can do to take charge of your health at LetsTalkFASDak.org.

This story was produced by the creative services department of the Anchorage Daily News in collaboration with LetsTalkFASDak. The ADN newsroom was not involved in its production.