Each year Bournemouth University (BU) holds a Festival of Learning (FoL), a week-long series of events aimed at encouraging members of the public, academics and healthcare professionals to engage with BU’s current science and research projects. This year BU’s Centre for Midwifery, Maternal and Perinatal Health (CMMPH) resumed the tradition of holding a debate during the festival on a topic relevant to maternal health and childbirth. In 2016 the FoL debate took place at the end of June and focused on the motion: " Advising pregnant women to avoid drinking alcohol during pregnancy is a symptom of the Nanny State and another step towards the medicalisation of childbirth.

Hundley, Vanora

Norton, Elizabeth Anne

van Teijlingen, Edwin

Westwood, G.

Wixted, D.

Bournemouth University Research Online

 1 Drinking in pregnancy: Poor guidelines or lack of evidence?  Authors: Wixted, D., Hundley, V., Norton, L., van Teijlingen, E., Westwood, G.     Contact:  Donna Wixted Clinical Doctoral Midwife Portsmouth Hospitals NHS Trust & Bournemouth University,  Bournemouth House Bournemouth University 19 Christchurch Road  Bournemouth BH1 3LH  dwixted@bournemouth.ac.uk  Tel: 07815 299 627   This paper has been published as: Wixted, D., Norton, E. A., Hundley, V., van Teijlingen, E. and Westwood, G., 2016. Drinking in pregnancy: poor guidelines or lack of evidence? Midirs Midwifery Digest, 26(4), 262 – 265               2  Background Each year Bournemouth University (BU) holds a Festival of Learning, a week-long series of events aimed at encouraging members of the public, academics and healthcare professionals to engage with BU’s current science and research projects.  This year BU’s Centre for Midwifery, Maternal and Perinatal Health (CMMPH) resumed the tradition of holding a debate during the festival on a topic relevant to maternal health and childbirth.  In previous years the CMMPH has covered the subjects of caesarean section on demand and the media’s role in creating fear around childbirth (Hundley 2013; Hundley et al., 2014).    This year’s debate took place at the end of June and forwarded the motion:   Advising pregnant women to avoid drinking alcohol during pregnancy is a symptom of the Nanny State and another step towards the medicalisation of childbirth.  The debate was chaired by Prof. Vanora Hundley, Professor of Midwifery in the Faculty of Health and Social Sciences, with two speakers for and two against the motion, each taking it in turn to present their case in carefully timed five minute slots (Figure 1).  An electronic voting system was employed to count votes for and against the motion in three stages; prior to the debate, after the speakers had completed their presentations and finally after discussion and summing-up had taken place.  The electronic system counted an initial total of 16 votes and it was interesting to note that prior to the debate, voting carried an even split of 50% for the motion and 50% against the motion.  The weekday post lunch-time timing of the event may have played a role in a reduced audience compared to previous years, as interested healthcare professionals may not have been able to attend due to work commitments.  Nevertheless, the audience was very much engaged and we had a fairly even split between male and female attendees.  The debate for the motion was opened by Prof. van Teijlingen, who outlined the  3 government’s recent changes to advice for pregnant women to avoid alcohol throughout pregnancy. This has been stated by the Chief Medical Officer (CMO) for England as precautionary advice due to there being limited evidence on what is a safe level for alcohol consumption in pregnancy, Figure 2 (DH 2015).  Expanding further on the theme of evidence, Prof. van Teijlingen drew the audience’s attention to updated guidelines published by the National Institute for Health and Care Excellence (NICE) which states there is no evidence that small amounts of alcohol harm the fetus, Figure 3 (NICE 2008).  Prof. van Teijlingen questioned the validity of advising women to avoid alcohol when the evidence does not support total abstinence and further suggested that such recommendations will limit a pregnant woman’s right to make an informed choice on drinking alcohol in pregnancy.  Prof. van Teijlingen cited two epidemiological papers that found no evidence that small amounts of alcohol affect fetal development (Kelly et al. 2009; Humphriss et al. 2013). He suggested that the abstinence message would unnecessarily scare women who drank prior to realizing they were pregnant, especially considering one in six pregnancies in the UK are unplanned.  He further added that imposing the CMO’s recommendation removes a pregnant woman’s participatory rights in her care and represents a further step towards the medicalisation of childbirth.  Prof. van Teijlingen believed this would increase the perception of pregnancy as a dangerous time for the mother and fetus rather than seeing pregnancy as a normal life event, citing a 2005 paper he wrote on medical models of birth (van Teijlingen 2005). Figure 1  The debaters For the motion Against the motion Edwin van Teijlingen, Professor of Reproductive Health, Bournemouth University Donna Wixted, Clinical Doctoral Midwife, Bournemouth University and Portsmouth Hospitals NHS Trust Dr. Liz Norton, Senior Lecturer, Public Health, Bournemouth University Dr. Greta Westwood, Research and Training Lead and Deputy Director of Research at Portsmouth Hospitals NHS Trust     4 Figure 2: Chief Medical Officer for England, DH 2015.   Opening the debate against the motion Donna Wixted stated that, as a midwife, she is aware that for pregnant women the primary outcome was for a healthy pregnancy and healthy child.  As such, Ms. Wixted explained that in pregnancy women expect to be advised by healthcare professionals on many aspects of health and lifestyle issues, ranging from the recommendation of supplements like folic acid and vitamin D to discussing possible risks associated with smoking and alcohol consumption (NICE 2008).   Ms. Wixted also affirmed a pregnant woman’s right to make informed choices and said in order to do so, pregnant women need to be aware of the risk of life-long neurological and developmental disabilities, collectively known as fetal alcohol spectrum disorder (FASD), that can result as a consequence of consuming alcohol in pregnancy and which, as stated by the British Medical Association (BMA), are entirely preventable if a pregnant woman does not drink alcohol in pregnancy (BMA 2007).  In addition, Ms. Wixted suggested that advising pregnant women who choose to drink alcohol, to drink no more that 1-2 units, once or twice a week, fails to recognize society’s lack of understanding concerning alcohol units in relation to strength of the alcohol and size of the measure, with the result that a pregnant woman may unintentionally consume more than NICE guideline amounts (NICE 2008).  Ms. Wixted believed that by advocating the CMO’s abstention recommendation, midwives could open the discussion about alcohol consumption in If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum.   Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk.   Most women either do not drink alcohol (19%) or stop drinking during pregnancy (40%).  The risk of harm to the baby is likely to be low if a woman has drunk only small amounts of alcohol before she knew she was pregnant or during pregnancy.   Women who find out they are pregnant after already having drunk during early pregnancy, should avoid further drinking, but should be aware that it is unlikely in most cases that their baby has been affected. If you are worried about how much you have been drinking when pregnant, talk to your doctor or midwife.   The expert group found that the evidence supports a ‘precautionary’ approach and that the guidance should be clear that it is safest to avoid drinking in pregnancy.    5 pregnancy with women and deliberate a number of issues, including the reasoning behind the CMO’s precautionary approach, why NICE guidelines do not support this, the risks of FASD and furthermore discuss what constitutes a unit of alcohol, thus facilitating a pregnant woman’s right to make an informed choice on alcohol consumption in pregnancy.   The second speaker for the motion was Dr. Liz Norton.  Dr. Norton presented the ethical, cultural and social perspective, stating that alcohol plays a significant role in many UK activities as well as being used as a stress reliever for many and questioned the role of public health authorities in interfering too much with personal choice.   Dr. Norton further recounted that pregnant women may feel stigmatized and ‘policed’ by other members of society, thus creating a situation where pregnant women feel discriminated against and could be said to have their human rights undermined.  Further to this, Dr. Norton questioned why the advice for abstinence is only targeted at pregnant women and failed to include both the role of partners and society in general or situations where a pregnant woman may view alcohol as an escape from domestic abuse. Figure 3: NICE: Antenatal care for uncomplicated pregnancies 2008 (updated March 2016)     The final speaker, speaking against the motion, was Dr. Greta Westwood who began by providing examples of her past experience as a nurse and midwife working with the families of children affected by FASD and the devastating effect FASD can have on a child’s development.  Thereby, Dr. Westwood raised the subject of the  6 rights of the unborn child and further outlined midwives’ responsibilities to pregnant women, as outlined by the Nursing and Midwifery Council’s Code (NMC 2015).  Pictorial examples were provided of the physical effect of the more severe form of FASD, known as fetal alcohol syndrome (FAS) and Dr. Westwood quoted the personal experience of Susan Fleisher, who adopted a child with FAS related disabilities and thereafter founded the National Organisation for Fetal Alcohol Syndrome UK (NOFAS-UK).   Dr. Westwood stated that all patients admitted to the acute medical unit in a hospital in the South of England are screened for alcohol consumption. She expressed concern that many women of child bearing years are drinking alcohol at alarming levels and so are increasing the risk of alcohol exposed pregnancies. Following the presentation of arguments for and against the motion, the audience was again invited to vote on the motion, based on the debate so far, with result that 63% found for the motion.  The floor was then opened to the audience for questions to the panel and the discussion covered a number of issues, including the difficulty in attributing symptoms of FASD solely to alcohol consumption in pregnancy and the international context of the new guidelines.  Further discussion on the role of society in policing pregnancies elicited a comment from one pregnant member of the audience, who confirmed that she felt her behaviour to be ‘observed’ when in public.   After discussion, both sides were given one minute to summarise their argument.  Prof. van Teijlingen went back to the evidence, or lack of evidence, and reiterated that a guideline based on a precautionary principle is a slippery slope that undermines pregnant women’s choices and threatens to further medicalise child-birth.  Ms. Wixted reminded the audience that a healthy outcome motivates pregnant women’s actions and it is the role of the healthcare provider to give all the evidence and discuss risks to help inform choice.  She added that the International Alliance for Responsible Drinking (IARD) provide a comprehensive table of international pregnancy and alcohol guidelines, revealing that countries such as the United States of America (USA), Canada, Australia, Denmark, Sweden and the Netherlands recommend pregnant women should abstain from drinking throughout their pregnancy, so it is not a whim of English health policy makers (IARD 2016). The audience was then given a final opportunity to vote, with the result that the  7 percentage in favour of the motion had swung further and the motion was carried with 82% for and 18% against.   While both those for and against the motion acknowledged that the audience attendance was small and perhaps more heavily weighted by academics rather than healthcare professionals, the discussion highlighted the importance for guidelines to be evidence-based.  The debate raised an important principle, namely the ethical considerations of ‘selling’ new guidelines to pregnant women based on a precautionary approach rather than on evidence, and doing so at a time when women can perhaps be said to be vulnerable to professional influence and are motivated to make lifestyle changes for the sake of their unborn child.  When considering implications for future practice, both sides of the debate recognised the importance of informed choice, although with the dissonance between the CMO’s precautionary recommendation of abstinence due to there being no known safe amount to drink in pregnancy and NICE guidelines stating there is no evidence that small amounts of alcohol affect the fetus, what women will choose as the best option for themselves and their unborn child is anyone’s guess.  References BMA: Board of Science., 2007. Fetal alcohol spectrum disorders: a guide for healthcare professionals. London: BMA. Department of Health., 2015. UK chief medical officer’s alcohol guidelines review. Summary of the proposed new guidelines., 2016. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/489795/summary.pdf    [Accessed 15 June 2016] Haynes, G., Dunnagan, T. and Christopher, S., 2003. Determinants of alcohol use in pregnant women at risk for alcohol consumption. Neurotoxicology and Teratology, 25, 659-666. Humphriss, R., Hall, A, May, A., Zuccolo, L., Macleod, J. 2013. Prenatal alcohol exposure and childhood balance ability: findings from a UK birth cohort study.  BMJ Open, 3;3:6 e002718 doi:10.1136/bmjopen-2013-002718 Hundley, V., Phipps, B., Treadwell, M., Baker, C., van Teijlingen, E. 2013. Intervention in childbirth: should we allow women to choose? The Practicing Midwife. 16 (11), 11-13. Hundley, V., Duff, E., Dewberry, J., Luce, A., van Teijlingen, E., 2014. Fear in childbirth: are the media responsible? MIDIRS Midwifery Digest, 24 (4), 444-447.   8 IARD., 2016. Drinking Guidelines for Pregnancy and Breastfeeding.  Available from: http://www.iard.org/policy-tables/drinking-guidelines-pregnancy-breastfeeding/ [Accessed 20 June 2016] Kelly, Y.J., Sacker. A., Gray, R., Kelly, J., Wolke, D., Head, J., Quiglry, M.A., 2012. Light drinking during pregnancy: still no increased risk for socioemotional difficulties or cognitive deficits at 5 year of age? Journal of Epidemiology & Community Health. 66 (1), 41-8 NICE: Antenatal care for uncomplicated pregnancies., 2008 (updated March 2016) Available from: www.nice.org.uk/guidance/cg62/chapter/1-Guidance#lifestyle-consideration [Accessed 05 July 2016] NMC., 2015. The Code: professional standards of practice and behavior for nurses and midwives. London: NMC.  Available from: https://www.nmc.org.uk/standards/code/read-the-code-online/.  [Accessed 05 July 2016] Törrönen, J. and Tryggvesson, K., 2015. Alcohol, health, and reproduction. An analysis of Swedish public health campaigns against drinking during pregnancy. Critical Discourse Studies, 12 (1), 57-77. van Teijlingen., E. 2005. Models of pregnancy and childbirth: A critical analysis of the medical model. Social Research Online, 10 (2). Available from: http://www.socresonline.org.uk/10/2/teijlingen.html [Accessed 05 July 2016]            

Drinking in pregnancy: poor guidelines or lack of evidence?

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