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The "No Drinking Rule" Shames Pregnant Women

The "no drinking pre or during pregnancy" rule is an inappropriate amplification of risk, and the cultural conversion of a guideline (in this case, the recommendation to abstain from consuming alcohol pre or during pregnancy) into a non-negotiable rule.
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The release of Emily Oster's new book, Expecting Better: Why the Conventional Pregnancy Wisdom is Wrong -- and What You Really Need to Know, sparked my interest in a topic I hadn't written about in a while -- the 'no drinking pre or during pregnancy' rule. Oster is quite right when she writes that pregnancy is treated as a one-size-fits-all affair, characterized by a seemingly endless list of rules of pregnancy do's and don'ts.

The rigidity of the rules to which new and expecting mothers are subjected is a topic I've discussed before. Mostly, I've taken issue with the ways in which breastfeeding guidelines have turned into rules -- anything other than full adherence puts a mother at risk for judgment as having failed, for having done something wrong, for being selfish, bad, or for not trying hard enough. Dogmatism towards breastfeeding has made infant feeing an emotional battlefield. Intense feelings of shame, guilt, fear and worry have become an all too common part of new mothers' feeding experiences.

A big part of the problem lies in how the scientific evidence is interpreted and presented to the public. It's a situation where both the risks of not breastfeeding exclusively, as well as the benefits of breastfeeding exclusively, are amplified way beyond what the evidence reasonably shows. As I've argued before, the educational and promotional literature has become biased, making it more a tool for persuasion than a tool for education.

Communicating statistics associated with formula and breast-feeding health outcomes is important, but so is ensuing that the safety margins are properly articulated. This is where we are failing miserably. Strategic framing of the whole risk-benefit dialogue inappropriately pits formula and breast milk as oppositional forces. This skews our perspective, and obscures the simple fact that both have been shown to be safe and acceptable options for infant feeding. The real risk is feeding your newborn foods other than either breast milk or formula.

We also need to do a better job of situating the relative health impacts of infant feeding within a broader context of risk. For example, how significant to overall health is the quality of a child's solid food diet compared to their infant diet? What ultimately presents a higher risk for respiratory infection: exposure to viruses (through a school-age sibling perhaps) or formula feeding? And just how significant is a respiratory infection to overall infant health in relation to other health concerns, such as accidents, for example?

Taking this kind of broader contextual perspective is important for all of us. Not only can it help families better evaluate the relative significance of their infant feeding decisions in relation to the myriad other health and parenting decisions they must make on a daily basis, it can also help relax the rigidity of our cultural dogmatism towards exclusive breastfeeding.

Because for many mothers the hardest part isn't the decision itself, it's the judgment and the guilt.

The "no drinking pre or during pregnancy" rule follows much the same pattern -- an inappropriate amplification of risk, and the cultural conversion of a guideline (in this case, the recommendation to abstain from consuming alcohol pre or during pregnancy) into a non-negotiable rule.

The no drinking rule has the same problems of bias in terms of how the scientific evidence has been translated and packaged for public consumption. We are led to believe that any drinking during pregnancy or even pre-pregnancy is a potentially serious risk even though this does not match what the scientific evidence actually says -- while the evidence is clearest for heavy and binge drinking, the evidence on light, occasional drinking during pregnancy is, at best, equivocal.

Refreshingly, the UK actually acknowledges this fact in their national guidelines, stating that if women "choose to drink alcohol while they are pregnant, they should drink no more than 1-2 units of alcohol once or twice a week. There is uncertainty about how much alcohol is safe to drink in pregnancy, but at this low level there is no evidence of any harm to their unborn baby."

Too bad we don't have an acknowledgment like that in our Canadian guidelines. Instead, we are simply and repetitively told (in large, bolded text) that "there is no safe amount or safe time to drink alcohol during pregnancy or when planning to be pregnant" and that all women who are pregnant or trying to get pregnant (or who may be at risk for pregnancy even if they are not actively trying) should abstain from alcohol altogether.

To me that's fear mongering. And medical paternalism. It's also only one part of the problem. A much bigger concern is with the unintended consequences of this kind of dogmatism. Just like the exclusive breastfeeding rule, dogmatism has made the no drinking rule a moral marker for good motherhood -- deviation means exposure to judgment, shame, guilt, worry and fear.

For women who imbibe on occasion before learning they are pregnant, it's one thing. But what does this kind of moral landscape mean for women who actually struggle to limit with their alcohol intake, who have difficulties stopping or cutting down? Judgment and shame won't fix a dependency problem. But it will drive it underground.

How many women end up not seeking help for alcohol dependency because of the intense stigma now associated with alcohol in pregnancy? How many struggle on their own, ashamed and afraid to reach out? By allowing the 'no drinking pre or during pregnancy' rule to become dogma, and by making it one of our key markers for maternal worthiness, we end up contributing to the very problem we are trying to solve.

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