Harm prevention?

Underlying the argument that the welfare of future children justifies the interference with women’s autonomy is the assumption that the policy will maximise the welfare of future children by preventing harm to them. If evidence does exist that screening for alcohol use in pregnancy is likely to prevent serious harm to future children then this may provide a justification for this routine screening.

What is the evidence here?

The guidance of the UK Chief Medical Officers (CMOs) that forms the basis of the approach of PHE adopts an abstinence only approach.25 The rationale for this approach is that the evidence on issue this is complex particularly when it comes to light or moderate drinking, where evidence is at best inconclusive and at worst contradictory with some studies, indicating that light and moderate drinking could be associated with better outcomes than abstinence2. It is thought that providing the detail of this information may be confusing to women and, thus, in order to prevent fetal harm (from heavy drinking), the conclusion arrived at is to remove this uncertainty and to advocate abstinence.26

Given this lack of evidence of correlation between light and moderate drinking and fetal harm, if undermining women’s autonomy is to be justified on the grounds that it is necessary in order to prevent harm to future children, it would be logical for the intervention to be targeted at the pregnancies most at risk of harm. However, the policy is not directed at those women who are believed to be drinking heavily during pregnancy, but at all women even though it is thought that only around 2.9% of pregnant women drink more than one alcohol unit a week.27 Nor is the policy aimed at detecting high levels of alcohol consumption, but any level of alcohol exposure, despite the lack of evidence that low to moderate alcohol consumption is harmful. Therefore, we argue that this policy cannot be justified as a proportionate interference with women’s autonomy in order to prevent harm to future children.

Better diagnosis of FASD?

It is also claimed that this policy will improve the welfare of future children because it will assist with the diagnosis of FASD.13 The hope here is that this, often difficult to diagnose, condition might be more easily identified with the use of information about the alcohol use of the child’s mother. However, it appears that while evidence that the child’s mother consumed alcohol during pregnancy might assist in linking these conditions to the mother’s behaviour, it is not necessary in order to diagnose the conditions themselves and determine the appropriate treatment and support.28 In fact, the SIGN 156 document itself notes concerns that there was ‘…no evidence identified which directly links a maternal history that has involved alcohol use to improved rates of diagnosis and better outcomes for a woman or her children’.29 Despite this, the same document recommends that routine screening be intensified with the use of biomarkers in addition to screening questionnaires.29

The use of routine biomarker analysis?

There is little evidence to suggest that the inclusion of biomarker analysis will lead to a more accurate record of maternal alcohol consumption. The PHE document draws on a 2018 study that compared the prevalence of alcohol consumption in the first trimester of pregnancy revealed by self-reporting and blood biomarker analysis.30 This study concluded that the prevalence of alcohol consumption estimated from blood biomarker analysis did not significantly differ from that revealed by self-reporting. Similarly, the SIGN 156 document notes that testing of meconium and placental tissues shows the greatest promise as blood biomarkers have been shown to be of limited use in screening for low and moderate alcohol consumption in pregnancy compared with self-reporting.31 If biomarker analysis is no better than self-reporting, what is the justification for using it? Meconium and placental tissue testing might be more accurate in revealing low and moderate alcohol consumption, but this would not be justified for two reasons. First, given the lack of evidence that low to moderate level alcohol consumption during pregnancy is likely to harm the future child, it is not clear what testing for this level of consumption would achieve. Second, testing of meconium and placental tissues is retrospective and cannot be used to identify women who might benefit from specialist support services to reduce their alcohol consumption during pregnancy and so could only be of use in making a retrospective link between the child’s conditions and the mother’s alcohol intake during pregnancy. A policy of routine screening using blood biomarker analysis or meconium and placental tissue testing would be even more of an infringement on women’s autonomy than routine alcohol questionnaires, given the physically invasive nature of this screening. The absence of evidence that these measures would improve the welfare of either the resulting child or the woman means that justification for this infringement is lacking.32

Counter productive?

Not only is there no evidence that the use of routine questionnaires and blood biomarkers would be likely to improve the welfare of children born, but there are also concerns that this more extensive investigation of alcohol use in pregnancy might actually prove harmful to the welfare of these future children. The pregnancies that are most at risk from harm associated with alcohol consumption are those where women are drinking heavily throughout their pregnancies. Given that these women are already reluctant to disclose their alcohol consumption to their healthcare team,33 most likely through fear of judgement and even of having their children removed from their care, it seems unlikely that a routine questionnaires and biomarker blood tests implemented to identify even low levels of alcohol will encourage these women to engage with antenatal care. This added level of surveillance and the distrust inherent in it has the potential to cause the women who would benefit most from good, supportive antenatal care, to disengage from that care, leading to far worse outcomes for them and their future children.34 The SIGN 156 document states that ‘no evidence was identified to suggest that asking about alcohol history had a detrimental effect on attendance for care’,17 but this could easily change with the increased pressure of being asked at every antenatal appointment, having this recorded on the woman’s (and potentially the child’s) health records and the use of biomarker screening. In addition, the proposed use of meconium and placental tissue testing might conceivably lead to women choosing to conceal births in fear of such testing revealing that they have consumed alcohol during pregnancy and the very real possibility that this could be used in care proceedings to remove the child from the mother’s care.35

The SIGN 156 document notes that some members of the development group reported that in their experience screening tools do not necessarily ensure that alcohol consumption is discussed effectively and that other issues such as experiences of violence and abuse need to be discussed.17 Indeed, it states that ‘To enable health behaviour change, including reduction in alcohol consumption during pregnancy, supportive relationships between patients and caregivers are key’.17 Despite the potential benefits, no recommendations are made relating to enhancing this supportive relationship and encouraging wider discussions of other issues in the woman’s life. Instead, it is recommended that use of biomarkers alongside screening questionnaires should be considered.17