Mixing medical advice, alcohol and pregnancy

This January, the European Society of Reproduction and Embryology made headlines after it counseled its members to refuse to provide reproductive treatment to "women used to more than moderate drinking and who are not willing or able to minimize their alcohol consumption." In its stance, the society unconsciously echoed the acidic formulation of renowned U.S. comic George Carlin: "Instead of warning pregnant women not to drink, I think female alcoholics should be told not to f**k."

What is most strange about the society's reformation of Carlin's modest proposal is that it doesn't seem strange at all to modern ears. Of course, a pregnant woman's drinking is bad for the child she's carrying. Of course, some women are so addicted to alcohol that they will value it over the health of their child-to-be. And of course, some pregnant women will drink even though they are warned of the danger that their children will get fetal alcohol syndrome (FAS) or the broader expression of alcohol-related damage known as fetal alcohol spectrum disorder (FASD).

And we can pronounce "of course" so emphatically because it feels as if people have known forever that alcohol and pregnancy don't mix. Even if the first time the syndrome was formally named and presented to the wider world was in a 1973 paper in the British journal Lancet, surely, ancients in many parts of the world must have realized that drink damages a fetus. Surely, they must have seen that alcohol could lead to deformed faces, stunted growth, torn memory, stumbled gait, linguistic gaffes, impulsiveness, failures at learning and a dozen other physical and cognitive manifestations that define people as fitting into one or the other of the five categories of FASD.

Surely, for thousands of years, pregnant women must have been counseled to cut down or eliminate their drinking.

Surely not. And that explains something about why drinking and pregnancy has remained such a conflicted area of human experience.

Biblical imbibing

Consider the following. Last year, James Sanders, a PhD student in psychology at the University of Alberta, wrote an article in the Canadian Journal of Pharmacology examining whether our forebears were aware of prenatal alcohol exposure and its effects, His conclusion: "Historical records do suggest an awareness of an interaction between alcohol and reproduction of some kind, as early as biblical times. However, these records do not necessarily suggest an awareness of the deleterious effects of alcohol on the developing fetus."

Much of Sanders's evidence is rooted in the learned, literate, passionate papers dissecting historical references to fetal alcohol syndrome written by Ernest Abel, a Canadian-born academic who now works at the C.S. Mott Center for Human Growth and Development at Wayne State University in Detroit. Abel's scholarship not so much deconstructs as demolishes efforts to find references to fears about alcohol's effects on fetal development in the Bible or the works of the Greeks, Romans and later Europeans.

Yes, there were worries about the effects of alcohol, but they centred on procreation rather than pregnancy. People knew if a man drank too much, he might have trouble getting aroused during sex. They knew that alcohol makes some men wild and that in that state, they might rape women. But they didn't know drink was harmful for a pregnant woman. Abel shows how all the remarks that seemed to suggest otherwise - for example, Roman Aulus Gellius's statement: "If a drunken man gets a child, it will never have a good brain" - either were never said or meant something else.

In terms of the latter, when the biblical Samson's mother was told not to drink while pregnant with him, it was not to protect her child from the ills of alcohol but rather, says Abel, to make him from birth a Nazirite - an individual who didn't drink or cut his hair. In more modern times, the London gin epidemic of 1720 to 1750 did create admonitions against drinking during pregnancy, but as soon as the mass drunkenness came to an end, doctors and the common person apparently forgot about alcohol's link to what was called "weak, fevered, distempered children."

This was so surprising to me that I gave Abel a call and asked whether there is any evidence that any people anywhere were aware of FAS in the past. His tart response: "In a word, no."

So, why did something that seems so evident now appear absolutely opaque in the past? Three obvious but not exclusive reasons come to mind.

Intrinsically small numbers

The figure regularly quoted (http://alcalc.oxfordjournals.org/cgi/reprint/33/3/195.pdf) is that somewhere between one and three in 1,000 newborns in North America have FAS and a bit less than one per cent of infants will show some alcohol-related effects.

Effectively, it looks as if FAS numbers are too small and too confusing for people in the past to have easily seen a connection between drinking and fetal physical and mental deformities that could have come from other factors.

No clear negative cause and effect

Even if the absolute numbers are small, if you could have seen that every woman who drank daily or binged occasionally had strange and deformed children, that would have directed ancient midwives and others to the deep truth about the poisonous effects of alcohol on the fetus. But that one-to-one correlation doesn't exist. A 2007 analysis of 14 studies looking at the effects of binge drinking on the fetus found "no convincing evidence of adverse effects of prenatal binge drinking." There was only a "possible exception" when it came to brain functions.

There also is not a direct cause and effect relationship between drinking habits of different nationalities and the rates of alcohol-related complications in the fetus. In a 1998 paper, Abel points out that the French drink 13 litres of alcohol per capita a year and the Americans 7.3 litres. Yet, the FAS rate in the U.S. is nearly a third higher than in France. He came up with a suite of explanations for this discrepancy, including binge drinking, the French habit of drinking alcohol mostly at meals and the possibility that drinking beer is more likely to lead to FAS than drinking wine.

But still, even if they wanted to believe too much drinking was bad for them, people in the past were faced with this paradox: the great drinking countries of the world aren't necessarily the centres of FAS-type symptoms.

Potential benefits of drinking

All of the above assumes that we know for certain that complete abstinence during pregnancy is best for the baby. And we don't.

A study of 18,553 British households reported last year that if a mother drank one or two drinks a week during pregnancy, her sons had fewer behavioural and hyperactivity problems, and her daughters had fewer peer-related and emotional problems than children of mothers who abstained. But even more striking, "boys born to light drinkers had higher cognitive ability test scores compared with boys born to abstainers."

There are a number of confounding factors in this report the higher economic and educational status of casual-drinking mothers among others and these would have confused a wise person in the past as much as they do us today. It might, indeed, look as if some drinking makes for brighter, better-behaved children.

Mixed messages

All of which feeds into what Gideon Koren, director of the Motherisk program at the Hospital for Sick Children in Toronto, describes as "[doctors] speaking out of both sides of their mouth." Koren regularly tells panicked women who drank before they knew they were pregnant that there is no evidence that a little drinking - even if it was a binge - is going to damage their child. Out the other side of his mouth, he also tells the same women that because nobody knows the exact limits of safe drinking, they shouldn't drink at all.

Which leads me to two disparate observations. I have been writing over the last little while about electronic health records. If you were looking for an absolutely perfect example of how researchers having access to everyone's health records might transform medicine, it is in the confused and confusing domain of FAS and FASD. When we collect information on every pregnant woman, her habits and otherwise her ethnicity, her economic status, and match these to the health data on her children, we should be able to speak much more authoritatively about how much alcohol an individual pregnant woman can safely drink and when.

That would allow us to replace guesstimates and fears with that singular thing that differentiates the medical wisdom of the present from the intuitions of human medicine of the past: real data. But lacking that, I propose that we all tweet the Nobel foundation and recommend that George Carlin be awarded a post mortem Nobelesque prize for the funniest, truest, most profane contribution by a non-scientist to helping us confused moderns understand why medical advice on alcohol and pregnancy doesn't always make sense.