It is well accepted that heavy alcohol consumption during pregnancy is a risk factor for fetal alcohol spectrum disorder, but research findings for exposure to low to moderate alcohol levels during pregnancy are equivocal, allowing a range of interpretations.
The 2001 guideline from the National Health and Medical Research Council (NHMRC) for low-risk drinking for “women who are pregnant or might soon become pregnant” recommends fewer than seven standard drinks per week, and no more than two standard drinks on any one day. This position has polarised health professional and consumer opinion in Australia.
The NHMRC guidelines on alcohol are scheduled for review in 2007. We surveyed the alcohol and pregnancy policies and clinical practice guidelines of Australia and six other English-speaking countries to identify current policy. Documents were obtained through Internet searches and direct contact with the relevant organisations.
The policies and guidelines varied both across and within countries, and the NHMRC guideline, while not universally supported in Australia, is in step with the policies of the United Kingdom and Canada.
Research is needed to elucidate the true association between low to moderate alcohol consumption and fetal harm, the impact of different policies on rates of maternal alcohol consumption during pregnancy, and any untoward outcomes of an abstinence message, to inform and underpin future policy development in Australia.
The issue of alcohol use during pregnancy is controversial. It is well accepted that heavy maternal alcohol consumption during early pregnancy — either chronic daily use or binge drinking (five or more drinks per occasion) — is required for the development of fetal alcohol syndrome (FAS),1,2 but not all children exposed to alcohol in utero will be affected to the same degree, and some will not be affected.3 A number of factors, such as the pattern and timing of alcohol consumption, stage of fetal development, and sociobehavioural factors, such as poverty and smoking, may exacerbate the impact of alcohol.4 Maternal nutrition, genetics and concomitant use of other drugs may also influence fetal risk. Alcohol exposure can also cause a range of alcohol-related birth defects and neurodevelopmental disorders which, collectively with FAS, comprise fetal alcohol spectrum disorder (FASD).5 The amount of alcohol necessary for fetal damage is unclear, and it remains debatable whether there is a threshold level below which alcohol does not harm the fetus.6
Lack of clarity in the published literature about the relationship between low to moderate alcohol consumption and fetal harm has allowed a range of interpretations and conclusions to be drawn from the data. The way each government and professional body interprets these data is reflected in their policies, and inconsistency in policy is evident not only between, but also within, countries.
In this article, we examine government policies on maternal alcohol consumption during pregnancy in seven English-speaking nations — Australia, New Zealand, Canada, South Africa, the United Kingdom, Ireland and the United States — and in Australian states and territories. Where available, policies and clinical practice guidelines of relevant medical, nursing, and non-professional organisations are also presented. This review is timely, in view of the upcoming revision of the guidelines on alcohol use in Australia by the National Health and Medical Research Council (NHMRC).
Alcohol and pregnancy policies and guidelines were identified through Internet searches of the websites of the relevant jurisdictions and organisations. Where no policy could be identified, the organisation was contacted by email or telephone. This strategy was based on the assumption that, to be useful tools, policies must be publicly available and easy to access.
In 2001, the NHMRC published revised alcohol guidelines based on a literature review.7 These guidelines reversed the previous (1992) NHMRC policy advising women to abstain from alcohol during pregnancy.8 Recommendations in the 2001 guidelines focus on avoiding a high maternal blood alcohol level. They advise that abstinence may be considered and that, if a woman does drink during pregnancy, she should consume no more than seven standard drinks a week and, on any one day, no more than two standard drinks, spread over at least 2 hours. They also advise that under no circumstances should a pregnant woman become intoxicated. The publication of these guidelines has generated considerable debate across Australia, and a review of the guidelines is scheduled for 2007, with a public consultation document to be finalised by the end of 2007.
The NHMRC 2001 guidelines have been adopted without alteration by only three organisations in Australia: the Australian Government Department of Health and Ageing, the Western Australian Drug and Alcohol Office, and the Tasmanian Department of Health and Human Services. The recently published National clinical guidelines for the management of drug use during pregnancy, birth, and the early development years of the newborn (2006),9 which were commissioned by the Ministerial Council on Drug Strategy, provide the NHMRC 2001 recommendations with a caveat that they are not, in the opinion of the authors, supported by sufficient evidence to conclude that any level of alcohol consumption during pregnancy is completely safe.
The perception that there is insufficient evidence to conclude that any level of alcohol consumption during pregnancy is low-risk is prevalent across Australian state and territory governments (Box 1). The Victorian Department of Health18 provides the NHMRC recommendations while advising that a safe level of alcohol consumption during pregnancy has not been determined. However, none of these policies and guidelines mention the basis for their recommendation of abstinence (Box 1).
All the Australian medical and nursing organisations that provide guidelines on alcohol and pregnancy have promoted abstinence as either the only option or the preferable or safest option (Box 2). None of the policies, with the exception of that of the Australian College of Midwives, which endorses the National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn, refer to a review of the evidence.
The policies and guidelines for alcohol and pregnancy in the other English-speaking countries reviewed — namely Canada,25-28 the UK,29-31 the US,32-37 Ireland,38 New Zealand,39,40 and South Africa41,42 — reflect the range of policies found within Australia, ranging from an abstinence message to advice that the risk from low amounts of alcohol is minimal (Box 3).
The Royal College of Obstetricians and Gynaecologists in the UK29 is the only organisation included in our review to have undertaken a systematic review of the literature. This systematic review appears to be the basis for the government policies in the UK.30,31 Six other organisations indicate that their policy is based on a review (not systematic) of the literature: Health Canada,25 the Public Health Agency of Canada,26 the Society of Obstetricians and Gynaecologists of Canada,28 the US National Institute on Alcohol Abuse and Alcoholism,33 the American College of Obstetricians and Gynecologists,35,36 and the American Academy of Pediatrics.37
The current lack of consensus on the evidence surrounding the potential for harm to the fetus from low to moderate levels of alcohol consumption during pregnancy is reflected in the variety of policy advice provided across the English-speaking countries examined. The policies identified can be grouped into three categories: those that recommend abstinence alone; those that recommend abstinence as the safest choice but also indicate that small amounts of alcohol are unlikely to cause harm (some indicate that women who cannot stop drinking should decrease their alcohol consumption during pregnancy); and those that advise that a low alcohol intake poses a low risk to the fetus. However, Australia and the UK are the only two countries where a quantity of alcohol has been specified. The UK recommends a maximum of four standard units per week (maximum of 32 g of alcohol), while Australia recommends no more than seven standard drinks per week (maximum of 70 g of alcohol), and both advise against binge drinking. Other policies stating that the risk from consuming a low level of alcohol is minimal refrain from quantifying a “low level” (Box 1 and Box 2). This may reflect the use of a safety factor, such as that recommended by some authors.2,43
Although women in Canada, Ireland and South Africa are advised to abstain from alcohol during pregnancy, the message is more complex than a simple abstinence message. For example, Health Canada advises that the consumption of low levels of alcohol is associated with minimal risk to the fetus; the Department of Health in Ireland advises women to avoid binge drinking; and the South African Department of Health advises that women who cannot stop drinking should reduce their alcohol consumption.
Public policy cannot be viewed in isolation. The impact of an abstinence message on women and their likely response to this message need to be considered. A recently published study of alcohol consumption by Western Australian women during pregnancy reported that 59% of the women surveyed reported drinking some alcohol during pregnancy, 14% reported binge drinking during the 3 months before conception, and almost half of the pregnancies (47%) were unplanned.44 These findings are similar to those of a Queensland study, in which half of the women surveyed consumed alcohol during early pregnancy, over a third (36%) consumed alcohol during late pregnancy, and 20% reported binge drinking (five drinks or more per occasion) at least once during early pregnancy.45 The results of these studies indicate that many pregnancies may be exposed to high levels of alcohol during the periconceptional period, before pregnancy awareness.
The possibility that an abstinence message will generate fear and guilt that results in harm was expressed by Dr Ian Walpole, a clinical dysmorphologist, geneticist and paediatrician who has conducted research into alcohol and pregnancy, in a letter tabled at the Australian National Council on Drugs Workshop on Fetal Alcohol Syndrome in 2002.46 The main concern relates to women with an unplanned pregnancy who have consumed alcohol before recognising they are pregnant and may consequently consider terminating the pregnancy. Similar concerns have been raised in Canada.47
National policy and guidelines on the use of alcohol during pregnancy, based on the evidence, should be viewed as one important step in the prevention of alcohol-related harm to the fetus. Consistency of the message is also important. In Australia, the difference in policies between and within states is likely to create confusion and lessen the impact of the policy.
Ensuring that guidelines are disseminated to health professionals and to women in the general population is a necessary component in the overall picture. Recent Western Australian surveys48,49 indicated that fewer than half of health professionals ask women about their alcohol use during pregnancy; and, although 87% advise women to consider abstinence, fewer than 13% provide advice consistent with all components of the NHMRC 2001 guidelines.
The NHMRC policy of 2001 is consistent with the policies from other countries and organisations that are based on a literature review. The variation in policy direction both between and within countries indicates the uncertainty faced by policymakers when the available evidence is insufficient or inconclusive, and identifies the need for more definitive research into the relationship between low to moderate levels of alcohol consumption during pregnancy and harm to the fetus.
Examination of the correlation between the policy and the prevalence and pattern of alcohol consumption during pregnancy in each of these countries may provide some insight into the effectiveness of policy dissemination and the way in which women interpret the message presented. The ultimate measure of effect would be to monitor rates of FASD. However, in Australia, the lack of complete ascertainment, even of cases of FAS — the severe end of the spectrum50 — and barriers to obtaining a true estimate48 limit our ability to obtain accurate data.
1 Policies on alcohol and pregnancy: Australian Commonwealth and state and territory governments*
2 Policies on alcohol and pregnancy: Australian medical and nursing organisations*
* Australian standard drink equals 10 g of alcohol. † Key to evidence base: 1 = systematic literature review; 2 = literature review (not systematic review); 3 = broad statement or indication that the policy is based on the evidence, but no specific references provided; 4 = consensus of authors; 5 = not mentioned.
3 Policies on alcohol and pregnancy: other English-speaking countries*