A Losing Gamble

By SHARI ROAN

June 11, 1997 12 AM PT

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TIMES HEALTH WRITER

Drinking while pregnant.

It’s a horrific game of chance, but in spite of a decade’s worth of public health messages proclaiming that there is no safe level of alcohol consumption in pregnancy, more pregnant women are drinking alcohol, according to new government data.

Four times as many pregnant women admitted to “frequent” drinking in the 1995 government survey compared to a similar 1991 poll. Among 1,313 pregnant women, 3.5% said they drank an average of seven or more drinks a week or had consumed five or more drinks on at least one occasion in the previous month.

Applied to the population of women pregnant at any one time, the 3.5% rate translates to 140,000 U.S. women drinking at dangerous levels during pregnancy. (An estimated 4 million women are pregnant at any given time.)

The data, drawn from a random telephone survey, was reported by the U.S. Centers for Disease Control and Prevention in the April 25 Morbidity and Mortality Weekly Report.

“These numbers are amazing,” said Lance Friedsam, president of the National Organization on Fetal Alcohol Syndrome. “If these numbers represent a valid population, it’s an enormous risk to unborn children.”

The apparent rise in drinking during pregnancy has both disheartened and stumped health officials because alcohol consumption rates among women in general have remained steady.

The survey also found that the percentage of pregnant women who reported any drinking--one drink or more--during the previous month rose from 12.4% to 16.3%, a finding that may indicate a general softening in public attitudes about the dangers of alcohol consumption during pregnancy.

“While abstinence from alcohol during pregnancy is the official recommendation from the surgeon general and the secretary of Health and Human Services, the effectiveness of that message appears to be diminishing from these data,” said Dr. Louise Floyd, chief of the Fetal Alcohol Syndrome Prevention Section at the CDC. “We need to know who is drinking at these levels and why these individuals may not be heeding this advice. That research may hold some promise of understanding this increase a little better.”

For now, however, health officials appear to be at a loss to explain why more pregnant women are putting their babies at risk.

“Most of the research up to this point led us to believe that, for the most part, women have gotten the message except for the highest-risk women, and that we should target intervention to the highest risk groups. But this [new data] makes me want to say maybe we should reassess the situation,” said Dr. Mary Dufour, deputy director of the National Institute on Alcohol Abuse and Alcoholism.

However, Dufour and others suggest the new CDC data may be flawed because the 1995 survey questions were changed slightly from the 1991 questions, which makes an actual comparison of the numbers impossible.

But even numbers that suggest no change in drinking patterns during pregnancy are a profound disappointment, said Janet Hankin, a professor of sociology at Wayne State University in Detroit who has studied drinking among pregnant women.

“We believe that there are about the same percentage of women drinking heavily during pregnancy. The important message is that the numbers haven’t decreased in spite of warning labels and public health messages,” she said.

Heavy alcohol use during pregnancy is linked to Fetal Alcohol Syndrome (FAS), a serious, irreversible birth defect that includes craniofacial abnormalities, mental retardation and growth deficiencies. But drinking during pregnancy can also cause less obvious consequences, sometimes referred to as alcohol-related birth defects, which include learning disabilities and behavior problems.

The dangers of drinking during pregnancy have been known for several decades. But it wasn’t until 1989 that warning labels specific to pregnancy were affixed to alcoholic beverages under federal law. Restaurants and bars typically carry similar signs or posters.

But officials now surmise that several trends have converged to dilute the earlier prevention efforts. In particular, they cite the lack of detailed public education on FAS as well as confusion over what “moderate” drinking is and how much alcohol consumption is safe during pregnancy.

“I’m wondering if the warning label has just become part of the scenery,” said Laurie Leiber, director of the Center on Alcohol Advertising, a nonprofit organization in Berkeley. “The impact kind of wears off and the behavior starts to go back. And maybe that is what has happened here.”

Studies at Wayne State show that the warning labels have had “a modest effect. But only among women who weren’t drinking heavily anyway,” Hankin said.

Abstinence has been a difficult message to communicate, officials say, because there is no evidence that a small amount of alcohol use during pregnancy is harmful.

“I think one reason [for the increase] may be that people may relate FAS to only the highest levels of alcohol, in the neighborhood of six to 10 drinks per day. But what we know--what the research has shown us in the past 20 years--is that there are effects of alcohol that can be measured at lower levels than those,” said Floyd. “People may think they are drinking at safe levels because they are not drinking at the level of FAS, but their children may have other effects.”

A safe “limit” of alcohol consumption during pregnancy has never been established, and the risks may even vary according to an individual’s genetic makeup and health habits.

“We don’t know what level is harmful and what level is safe, and there is probably no way of determining that,” said Dr. Hilda Hutcherson, assistant professor of clinical obstetrics and gynecology at Columbia-Presbyterian Medical Center in New York City.

But rationalizing that a certain amount of alcohol during pregnancy is OK “is apparently what a lot of women are doing,” said Marion Greenup, chief of staff at the March of Dimes. “FAS is entirely preventable. We shouldn’t be caught up in, ‘How much can I get away with?’ The point is, why take the risk?”

Due to a combination of factors--such as when alcohol is consumed in pregnancy, in what amounts and genetic factors--women who drink heavily in pregnancy have a 50% chance of giving birth to a baby with full-blown FAS, Hankin said.

“It kind of becomes a game of chance,” she said. “We also know that women who drank in previous pregnancies are more likely to drink in subsequent pregnancies. She may reason, ‘In my previous pregnancy nothing happened; my baby appeared OK. Why should I listen to these warnings?’ ”

Studies also show Americans generally underestimate how much alcohol is risky, Leiber said. A recent Center on Alcohol Advertising survey showed many Americans incorrectly define “moderate” drinking. According to U.S. Dietary Guidelines, moderate alcohol intake for non-pregnant women is no more than one drink a day (12 ounces of regular beer, 5 ounces of wine or 1 1/2 ounces of distilled liquor).

“What if a pregnant woman thinks drinking five beers on one occasion is moderate?” Leiber said. “We need to give people much more concise information.”

While researching a book for pregnant African Americans, Hutcherson said she was surprised at the number of women who assumed certain drinks were safe.

“I spoke to a large number of women who felt it was OK to drink certain types of alcohol; vodka and gin were bad and wine coolers and beer were OK. They weren’t aware that alcohol is alcohol,” she said.

Americans may even be mistaken about how much they should fear FAS and other alcohol-related birth defects, experts say. One survey showed that only 29% of women of childbearing age could correctly describe FAS. Several surveys have shown that more than half of the respondents described FAS as “being born addicted to alcohol.”

“People think it means it’s a drug baby. That implies that the baby can dry out and be just fine. But FAS is a lifelong set of disabilities,” Dufour said.

FAS cases have increased steadily since 1979, an increase that officials have--until now--attributed to more accurate diagnosis. FAS is the leading cause of birth defects in the United States with an estimated rate of 6.7 cases per 10,000. However, officials concede that many cases go undiagnosed.

“I can tell you that most scientists think that the number of children with FAS is grossly under-reported,” said Friedsam of the National Organization on Fetal Alcohol Syndrome. “Many children aren’t diagnosed until they are beginning to go through the rapid-development stages of talking, walking, etc. If they don’t carry the physical symptoms of FAS, people say they’re slow and will catch up or they may be diagnosed with other disorders that are more socially acceptable.”

Denying the impact of FAS and alcohol-related birth defects, however, costs the nation greatly, about $2.1 billion per year, according to the National Institute on Alcohol Abuse and Alcoholism.

A major effort of the CDC will be to determine the effectiveness of the messages that pregnant women receive from health-care providers.

“It’s in the interests of managed-care companies to do more about this,” Friedsam said.

Women may need both stronger messages not to drink and more support for their efforts.

“This problem is a very good example of how culturally embedded drinking behavior is in our society and that you don’t tease out one little part and expect behavior to change,” Floyd said. “It’s a very deep, persistent problem. And we have to step back and look at it more broadly to make a sustained change.”

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

A Growing Problem

The number of women who drink alcohol during pregnancy continues to rise, according to a recent government report. However, the drinking rates among women in general have remained even.

PREGNANT WOMEN (U.S. women ages 18-44)

Any drinking (At least one drink in preceding month)

1991: 12.4%

1992: 16.3%

More than five drinks on one occasion

1991: 0.7%

1992: 2.9%

Frequent drinking (An average of seven or more drinks per week or five or more drinks on at least one occasion)

1991: 0.8%

1992: 3.5%

ALL WOMEN

Any drinking