For women who experience unplanned pregnancies, official guidance to abstain from alcohol may be welcome or useful once they know they are pregnant. However, it’s not going to make any difference to alcohol exposure or alcohol-related harm before this point. Natalie Davies describes an approach with potential to prevent alcohol-related harm among women at risk of unplanned pregnancies, but has some questions about the lifecourse approach that underpins it.
Up until at least 2014, the Royal College of Obstetricians and Gynaecologists and National Institute for Health and Care Excellence advised that women should not drink at all during the first 12 weeks, and thereafter should limit consumption. These recommendations identified the first trimester as a pivotal time for the continuation of the pregnancy, and a period of potentially elevated harm to the embryo/fetus. Although more recent guidelines have avoided the subject of higher risk and lower risk times to drink, expert bodies such as the British Medical Association still acknowledge that some stages of pregnancy may be more vulnerable than others.
Current public health advice to abstain from alcohol throughout pregnancy (i.e. from conception to birth) overlooks two important reproductive realities for women: almost half of pregnancies in the UK are unplanned; and there is a period of time at the start of pregnancy (usually a matter of weeks) when a woman is unaware that she is pregnant.
Whether the level of risk of alcohol-related harm remains constant in pregnancy, or can be heightened in periods like the first trimester, current public health advice to abstain from alcohol throughout pregnancy (i.e. from conception to birth) overlooks two important reproductive realities for women: almost half of pregnancies in the UK are unplanned; and there is a period of time at the start of pregnancy (usually a matter of weeks) when a woman is unaware that she is pregnant.
Getting a better understanding of early pregnancy
Some pregnancy tests may be able to detect pregnancy from as early as eight days after conception. However, these are only really useful for women who suspect they could be pregnant – for example, because they are trying to conceive. For many women the earliest cue would be that they are late for their menstrual period.
A study of trends in US women found that, on average, women become aware of their pregnancies at between five and six weeks’ gestation. This doesn’t mean five to six weeks after conception, though. For a woman with a 28-day cycle, five to six weeks pregnant is approximately one to two weeks late for her period, as the standard way of counting pregnancy is from the first day of a woman’s last menstrual period (roughly two weeks before conception). So, on average, women find out about their pregnancies half-way through the first trimester.
In individual women, there are many factors that can further delay recognition of pregnancy, including: not having regular cycles; experiencing a lack of pregnancy symptoms; having a condition with symptoms similar to pregnancy, such as chronic pain; being unfamiliar with pregnancy symptoms; using hormonal contraceptives that stop menstrual periods altogether; and mistaking symptoms of pregnancy with symptoms of a hormonal contraceptive.
Giving women CHOICES
Over a decade ago in the United States, the Changing High-Risk Alcohol Use and Improving Contraception Effectiveness Study (CHOICES) tested a way of preventing alcohol-exposed pregnancies. The intervention focused on women who were drinking at hazardous or harmful levels, and were not consistently or effectively using contraception. Through four sessions of motivational interviewing and a contraceptive counselling session, the intervention sought to reduce risky drinking and reduce the risk of unplanned pregnancies.
A 2007 trial of CHOICES found that significantly more women in the intervention group reduced their risk of an alcohol-exposed pregnancy after nine months than women in the information-only control group, and were much more likely to reduce their risk of an alcohol-exposed pregnancy through addressing both their drinking and use of contraception. Numerous other studies have demonstrated its effectiveness, and CHOICES has been rolled out nationwide with the aid of funding from the Substance Abuse and Mental Health Services Administration and the Centers for Disease Control and Prevention.
CHOICES Plus was the next generation of the intervention. In 2017, researchers trialled the effectiveness of the intervention with two amendments: they added tobacco consumption to the list of target behaviours; and they cut the number of sessions of motivational interviewing in half. Just as with CHOICES, women in the CHOICES Plus intervention group had a significantly lower risk of alcohol-exposed pregnancies nine months later, and more women in the CHOICES Plus group reduced both of the risk factors for alcohol-exposed pregnancies.
Applying a lifecourse approach to protecting health
CHOICES and CHOICES Plus were described in the literature as ‘pre-conception’ services – a term which refers to the period before pregnancy. To the reader, this might sound like a peculiar designation. ‘Why would they call them pre-conception interventions if the interventions were designed to prevent pregnancy from occurring?’
The vernacular comes from a lifecourse view of health, which suggests that adverse conditions during critical periods can have “lasting or lifelong effects on the structure or function of organs, tissues and body systems”. Pregnancy is one of these critical times in a person’s lifecourse, and a big concern in recent years has been the potential for alcohol consumption in pregnancy to cause irreversible harm to the embryo/fetus.
The term ‘pre-conception’ reveals that the principal drive for CHOICES and CHOICES Plus was to prevent harm at the start of another person’s lifecourse. In other words, it was not to prevent alcohol-related harm to the woman for her own sake, or prevent an unplanned pregnancy for her own sake; it was to prevent heavy drinking and unprotected sex because that behaviour was perceived to put a hypothetical pregnancy at risk.
Although the constituent parts of the CHOICES and CHOICES Plus interventions may have had a meaningful impact on women’s lives (e.g. reducing alcohol-related harm, and finding an appropriate form of contraception), these outcomes were not the focus of the intervention.
Assuming a state of ‘pre-pregnancy’
Pre-conception policies and interventions ascribe a state of ‘pre-pregnancy’ in order to justify action that can prevent harm to an embryo/fetus that doesn’t yet exist, and may never exist.
The lifecourse approach to conceptualising harms and delivering interventions is well-intentioned, of course – but, depending on how it is applied, can be incredibly problematic for women of ‘childbearing age’.
Pre-conception policies and interventions ascribe a state of ‘pre-pregnancy’ in order to justify action that can prevent harm to an embryo/fetus that doesn’t yet exist, and may never exist. This perspective was evident in an early draft of the World Health Organization’s global action plan on alcohol. Published in June 2021, the action plan proposed preventing drinking among pregnant women and women of childbearing age:
“It is necessary to raise awareness among decision-makers and the general public about the risks and harms associated with alcohol consumption. Appropriate attention should be given to prevention of the initiation of drinking among children and adolescents, prevention of drinking among pregnant women and women of childbearing age, and protection of people from pressures to drink, especially in societies with high levels of alcohol consumption where heavy drinkers are encouraged to drink even more.”
Unsurprisingly, the suggestion that women between the age of 18 and 45 should avoid drinking alcohol altogether as a precaution for pregnancy was met with a swift backlash, including from UK women’s healthcare charity, the British Pregnancy Advisory Service (1 2). The World Health Organization removed the reference to ‘women of childbearing age’ in a subsequent draft of the action plan, and released a statement clarifying their approach:
“The current draft of WHO’s global action plan does not recommend abstinence of all women who are of an age at which they could become pregnant. However it does seek to raise awareness of the serious consequences that can result from drinking alcohol while pregnant, even when the pregnancy is not yet known.”
Although women’s organisations and advocates were undoubtedly relieved that the World Health Organization corrected the action plan, this was not an isolated incident. Another blog on the SSA website discusses draft guidelines from the National Institute for Health and Care Excellence (NICE), which were created to aid the diagnosis of fetal alcohol spectrum disorders. The blog suggests that these guidelines, which have yet to be finalised, expose the tension between women’s rights and particular applications of the lifecourse perspective.
This article was published as part of The Pregnancy Edit for September 2021. If you are interested in writing a blog or participating in an interview about alcohol-related harm in pregnancy for the SSA website, please contact Natalie Davies at natalie@addiction-ssa.org.
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