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May 14, 2019

'Don't drink while pregnant': Could this common warning actually backfire?

Daily Briefing
    Editor's note: This popular story from the Daily Briefing's archives was republished on Apr. 6, 2021.

    State policies that warn against drinking while pregnant and those aimed at helping women who drink while pregnant may actually be backfiring and harming babies, according to a new study published in PLOS One, Anna North writes for Vox.

    Infographic: Take a closer look at women’s pregnancy care preferences


    In 1973, a paper published in The Lancet revealed that alcohol consumption during pregnancy can cause fetal alcohol syndrome, a condition that can impede brain development, affect growth, and cause distinctive facial features.

    Today, research has shown that drinking while pregnant also can cause miscarriage, stillbirth, or a range of other disabilities called fetal alcohol spectrum disorders (FASDs). People with FASDs can have difficulties with learning, memory, and speech, as well as delays in language and problems with certain organs like the heart and kidneys.

    In the decades since the paper in The Lancet was published, policymakers have tried to develop ways to discourage pregnant women from drinking, North writes, such as requiring warning signs about the effects of drinking while pregnant in places where alcohol is sold.

    However, a new study adds to a growing body of research that suggests these policies might not be working.

    Study casts doubt on certain pregnancy-related alcohol policies

    In the study, Meenakshi Subbaraman, a biostatistician at the Public Health Institute, and Sarah Roberts, an associate professor of obstetrics and gynecology at UCSF's Advancing New Standards in Reproductive Health, note that existing research "suggest[s] that alcohol/pregnancy policies may scare women who drink during pregnancy such that they avoid prenatal care utilization, which may contribute to worse birth outcomes."

    For the latest study, Subbaraman and Roberts sought to add to that research by determining whether eight alcohol/pregnancy policies, including those aimed at helping pregnant women access treatment for substance use, were associated with an increase in the number of prematurely born babies or babies born at a low birth weight, and the associated costs.

    The researchers found four policies in 2015 were significantly related to higher numbers of prematurely born babies or babies born at a low birth weight:

    • Defining substance use during pregnancy as child abuse or neglect;
    • Giving pregnant women priority for substance abuse treatment;
    • Limits on criminal prosecution; and
    • Mandatory warning signs in establishments that sell alcohol about alcohol's risk for fetal health.

    The researchers noted that policies that mandated warning signs and defined substance use during pregnancy as child abuse or neglect were the most popular among states in 2015 so they appeared to have the greatest negative effects. For example, the researchers found mandatory warning sign policies were associated with an additional 7,375 babies born at low birth weight, while those defining substance use during pregnancy as child abuse or neglect were associated with an excess of 12,372 prematurely born babies. The researchers estimated those adverse outcomes resulted in nearly $152 million and more than $582 million in additional costs in the first year of life, respectively. 

    The researchers noted that giving pregnant women priority for substance abuse treatment was associated with an excess of 7,284 low-birth weight babies and 9,778 preterm babies, costing an additional $150 million and $460 million, respectively, in the first year of life. Meanwhile, limits on criminal prosecution was associated with an excess of 2,028 low-birth weight babies and 3,993 preterm babies, costing an additional $42 million and $188 million, respectively, in the first year of life.

    The researchers found no significant increases in low-birth weight or preterm babies related to the remaining four policies:

    • Civil commitment,
    • Child protective services reporting requirements;
    • Reporting requirements for data or treatment purposes; and
    • Prioritizing treatment for pregnant women and women with children.

    Why the policies may be ineffective

    Roberts said she noticed that many pregnant women often avoided getting prenatal care because "they were really scared of being reported to Child Protective Services and having their children removed" because they drank while pregnant. Not getting enough prenatal care can lead to complications like premature birth, North writes.

    Moreover, Roberts said while some states limited criminal prosecution of women, women might not know that and still fear the potential for prosecution, which in turn could lead them to avoid prenatal care. In addition, she said when punitive policies were reversed, states typically did not also work with doctors to find solutions to reduce alcohol use in pregnant women.

    Other pregnant mothers were afraid that their drinking "had already irreversibly damaged their babies, and that if they went to prenatal care, that they would get some confirmation of that," or maybe be judged by a doctor or have their use of alcohol publicized in some way, Roberts said.

    This fear of having already done irreversible harm could also lead the pregnant mothers to continue drinking, Roberts said. While research shows stopping drinking later in pregnancy could help the fetus, Roberts explains some women may believe that since "they've already used earlier in their pregnancy, and so it doesn't matter what they do now."

    Roberts and Subbaraman wrote in their paper that it's especially surprising that policies aimed at helping pregnant women who drink or misuse drugs also have negative effects. However, Roberts said it's possible that states that give priority for substance misuse treatment to pregnant women may already have a shortage of treatment options. "[I]t might be an indication of something else going on in the treatment delivery system more broadly," Roberts said.


    David Jernigan, a professor of health law, policy, and management at Boston University who was not involved in the study, said the results of this study can help draw attention to the potential harms of state alcohol policies.

    "It's really important that they're looking at this," he said, "because the last thing we need is not only ineffective policies but ineffective policies that target a vulnerable population."

    Jernigan added that policies to make alcohol more costly and less accessible, namely by raising alcohol taxes and limiting when and where it's sold, have been shown to reduce alcohol consumption.  

    Roberts said the results of this study suggest that "a pause is in order" when it comes to state alcohol policies until policymakers figure out what actually works to help pregnant women. "What we need is to step back and start again and center the voices of people who are using during pregnancy and the people who take care of them," Roberts said.

    The results from this study also suggests that doctors may need to talk to their pregnant patients differently, Roberts said. For example, doctors can communicate clearly that just because someone drank earlier in their pregnancy doesn't mean stopping wouldn't still benefit their baby. "We need to be more careful about the health messages related to potential harms from use during pregnancy," Roberts said. "Scaring people is not necessarily having the intended effect" (North, Vox, 5/8; Subbaraman/Roberts, PlosONE, 5/8).

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