Pregnancy and Policy: Who Decides? Time to Stop Focusing on Fear and Shame

Fetal alcohol spectrum disorders (FASDs) are completely preventable. FASDs are caused when alcohol, consumed during pregnancy, crosses the placenta and can result in effects that range in severity. The exact prevalence is unknown, but it is estimated that at least 10 out of 1,000 children have FASD (May & Gossage, 2001). This estimate, though high, may still fall short of the actual cases due to the window in which a diagnosis occurs. While the most severe cases of FASD are obvious at birth, less subtle effects of FASD, such as developmental, cognitive, and physical disabilities, may not be obvious until the child ages, delaying diagnosis and treatment. FASD is a public health issue where prevention is our best approach. The questions remains: How do we prevent FASD while preserving a person’s autonomy before and during a pregnancy?

With 1 in 10 people drinking during pregnancy (CDC, 2015), the solution is more complicated than simply asking people to abstain from alcohol use while pregnant. Almost 50 percent of all pregnancies in the US are unplanned, which can delay pregnancy awareness (Guttmacher, 2016). Unplanned pregnancies can result from a lack of knowledge about or access to birth control. Many people are unaware of their pregnancy for eight weeks or more and drink during this window of time. Consuming alcohol during this window unknowingly and unintentionally exposes the fetus to alcohol’s potentially damaging effects. People who become pregnant may be unaware of the effects of alcohol exposure on the developing fetus, or may need support to minimize or abstain from alcohol use. Furthermore, those who suffer from serious addiction or mental health issues require a network of support to address their drinking. In order to address the complexity of FASD, we must understand the very important intersections between access to contraception and education about alcohol’s effects on the fetus.

This is an issue that has not gone unaddressed. The CDC recommends that reproductive-age women, not using birth control, should abstain from drinking any alcohol (CDC, 2016). Abstinence is the safest approach, but provides no educational information about why one should abstain or how one can access health care, counseling, or birth control. This abstinence-based approach does not address underlying trauma, mental health issues, or access for treatment of alcoholism. Given that a large portion of the population enjoys responsible drinking, suggesting abstinence from alcohol is an unrealistic expectation. This approach comes off as paternalistic and infers that women’s participation in the world is solely to produce offspring. Another strategy that has been used is point of sale warning posters and labeling on alcohol-containing products. While these strategies demonstrated a small decrease in FASD, the effect has waned as people have tuned out these familiar messages. While some providers screen for alcohol use, there is no universal screening for alcohol use in the obstetric setting. These prevention initiatives have failed as they do not address the multifactorial nature of FASD.