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Submission from the bpas to APPG on FASD

Bpas submitted the following to inform an inquiry launched by the All Party Parliamentary Group on Fetal Alcohol Spectrum Disorder (FASD). The APPG is calling for all pregnant women to abstain from alcohol for the duration of their pregnancy in order to prevent FASD.

The British Pregnancy Advisory Service is a reproductive healthcare charity which sees 70,000 women every year for advice about an unplanned pregnancy or a pregnancy they cannot carry to term, providing compassionate abortion care for those who decide to end the pregnancy and referral into antenatal care for those who decide to continue. The majority of our services are carried out under contract to the NHS. We have also been the principle partner in an ongoing project with NHS London: “As Soon As You’re Pregnant” to encourage pregnant women to tell their GP or self-refer into maternity care on confirmation of a pregnancy in order to ensure the best possible outcomes for themselves and their babies – not least by providing early access to specialist support and services for pregnant women with dependency issues. We are concerned about the discussion around alcohol consumption in pregnancy for the following reasons:

1.         Pregnant women have the same right to evidence-based information on health-related matters as any patient group, and should not be misled. There is no evidence that drinking within the levels recommended by NICE causes harm to the baby, and women should not be advised otherwise.

2.         Messages that suggests any alcohol in pregnancy can cause incurable birth defects are now manifesting themselves as a factor in some women’s decision to end an unplanned pregnancy, particularly among women who are unsure about continuing their pregnancy, and is causing high levels of anxiety among women who do decide to continue with their pregnancy.

3.         Catch-all approaches, which expose low risk and high risk drinkers to the same messages, will do nothing to help the small number of pregnant women with alcohol problems and divert attention away from what could be done to best support them.

Around half of pregnancies in the UK are not formally planned (Natsal-3), in part because contraception frequently lets women down, and around half of women of reproductive age report having drunk alcohol in the last week (ONS 2015). This means that many women will have consumed alcohol before they recognised they were pregnant. This is the most likely explanation for the findings of the recent BMJ Open study, Prevalence and predictors of alcohol use in pregnancy, in which nearly one third of pregnant women reported an episode of binge drinking in the first trimester, falling dramatically to less than 1% in the second trimester. Once women confirm pregnancy, alcohol intake reduces significantly. Only a third of women reported consuming alcohol in the second trimester, and the vast majority of these (96%) drank within the NICE guidance levels of 1-2 units, once or twice a week. These findings correspond to those published by the Health and Care Information Centre (HSIC), which found pregnant women had an extremely low average intake of alcohol, with just 3% drinking more than 2 units per week. These findings suggest women are extremely conscious of the potential risks of heavy intake in  pregnancy and reduce their consumption accordingly. If a pregnant woman wishes to consume alcohol she should be entitled to take her own decision on this in accordance with the available evidence. There exists no evidence of harm at these levels.

Messages that small amounts of alcohol cause brain damage and life-long disability may be well-intentioned, but they are having unintended consequences.  Unplanned pregnancy is prevalent. bpas is regularly contacted by women considering abortion because of an episode of binge drinking before pregnancy confirmation, as well as those with continuing pregnancies who are highly anxious and seeking some reassurance. Isolated episodes of heavy drinking in early pregnancy are extremely unlikely to have caused their baby harm. (Pediatric Research (2008) 64, BJOG vol 19, issue 10, 2012, J Epidemiol Community Health 2007;61).  bpas would like to see more reassurance to the many women who find themselves in this situation, and that if the pregnancy is otherwise welcome, they should not feel they need to terminate on the basis of alcohol consumption. We are sure the APPG would not want to cause more distress to pregnant women at what can already be an extremely stressful time in their lives – particularly for those who are struggling to make a decision about an unplanned pregnancy.

bpas would wholeheartedly welcome an evidence-based approach to FASD, and supports the APPG’s objective of researching the prevalence and impact of FASD in the UK today. Clearly using historical estimates of FASD in the US and extrapolating them onto the UK birth rate is hugely problematic. We also need to explore how best to support pregnant women with alcohol dependency issues, and suggest this may be a more productive way of proceeding than calling for the mandatory labelling of drinks containing alcohol warning against consumption in pregnancy. As previously noted, there is no reason for a pregnant woman not to enjoy an alcoholic drink if she wishes. But a major review of the existing literature on such labels also concluded they do nothing to change the drinking behaviour of those who drink heavily or binge during pregnancy. (International Journal of Alcohol and Drug Research, 2014).  

Research into developing evidence-based measures that encourage women to book in and attend antenatal care in the knowledge they will receive non-judgmental care and support to reduce their intake should be investigated. As the BMA notes, Foetal Alcohol Syndrome is a complex condition, in which the nutritional status of the mother, smoking, genetic disposition, socioeconomic status and general health among other factors all play a role, explaining why only 5% of babies born to mothers with alcohol dependency are affected by the full syndrome presentation (BMA, 2007).  It is clearly the case that maternal nutrition is affected when alcohol intake forms a significant part of a woman’s diet, and it is interesting to note emerging research into neurodevelopmental delay among the children of women who suffered Hyperemesis Gravidarum, which also compromises maternal nutrition. bpas therefore welcomes ongoing studies looking at how nutritional deficiencies may influence FAS, and how nutritional supplementations could offset some of the effects. 

We look forward to the APPG’s work exploring how best to assist the pregnant women who need support in a manner which respects their individual needs and personal autonomy.