Sorting Out Ambivalence Over Alcohol and Pregnancy
"When Janet Golden was kicking around in utero 53 years ago, pregnant women of her mother's generation were encouraged to enjoy their 5 o'clock cocktails. A martini calmed nerves; a glass of wine helped a woman to sleep. But don't drink too much, obstetricians cautioned: all those empty calories!
By the mid-1960's, many obstetricians even believed that alcohol could halt premature labor. As noted by Dr. Golden, now a medical historian at Rutgers University in Camden, N.J., when women arrived at the hospital in premature labor, they were often handed a vodka and orange juice or given alcohol intravenously.
But in 1973, a new diagnosis, fetal alcohol syndrome, had been identified in the children of women who drank heavily during pregnancy. The symptoms included diminished I.Q., small stature, flat face and drooping eyelids.
In her new book, ''Message in a Bottle: The Making of Fetal Alcohol Syndrome'' (Harvard University Press), Dr. Golden argues that the political, legal, medical and social response to fetal alcohol syndrome has been inconsistent, often illogical and frequently volatile.
If alcoholism has been acknowledged as a disease, she observes, then why have pregnant women who drink been charged with child abuse?
Ultimately, she writes, fetal alcohol syndrome is a template on which society continues to rewrite its ambivalent feelings about pregnancy, maternal responsibility, the rights of the fetus and alcoholism.
In a telephone interview from her home outside Philadelphia, where she lives with her husband and two sons, Dr. Golden said she hoped that her book would be read as an argument for more and better treatment programs.
Despite the mandatory labels on every bottle of alcohol now sold in the United States that warn pregnant women not to drink, she said, the syndrome ''is still a relatively common birth defect.''
Q. What started you thinking about fetal alcohol syndrome?
A. I was fascinated by the labels on the liquor bottles. It puzzled me as to why the first warning was about pregnancy, and not about drunk driving, which kills many more people.
As a historian, I asked: surely we must have been thinking about women and pregnancy and drinking for a long time; why are we thinking about it this way now?
Q. Before fetal alcohol syndrome was identified, how did we think about women and pregnancy and drinking?
A. Actually, for most of Western history, societies had been mostly concerned with alcohol abuse by men. It was more prevalent, it was more visible, and it was linked to violence and social disorder. It had enormous social cost: men drank up their wages, beat their wives and children, lost jobs, went to the poorhouse.
There was always a concern about whether alcohol affected sperm. People thought it was all there in the egg, and the sperm had to liven it up.
Q. So why were Americans finally able to accept that alcohol could have an impact on a fetus?
A. By 1973, we'd been through thalidomide and the rubella epidemic, which let people understand that the womb was not a protective barrier and that fetuses could be damaged by exposure in utero. Alcohol, too? O.K. That makes sense. And abortion looked like a quick fix to F.A.S. In the early days of Roe v. Wade, physicians openly talked about recommending abortions to pregnant alcoholic women. So: ''We've discovered F.A.S., but we have a solution.''
Q. How did the beverage industry react to having to label every liquor bottle with warnings?
A. They fought labeling tooth and nail when it was first proposed. They didn't want to have an admission on their packages that there were risks involved in drinking.
But after the Cipollone decisions about federal tobacco labeling, they saw that labeling might indemnify them from lawsuits. So they did a political turnaround. Instead, they worked very hard to make sure the warnings didn't appear on the front of bottles and that, most importantly, they didn't appear in beverage advertising, and particularly beer advertising, on TV.
Q. When we as a society concern ourselves with pregnant women who drink, who is the primary patient, the woman or her fetus?
A. By the 1980's and crack babies, we shifted our attention from the problems of women struggling with substance abuse who need health care to taking a criminal justice approach that said, Bad women are doing bad drugs and harming fetuses. Now we had guilty mothers and innocent babies. There was an erosion of sympathy for the women struggling with drinking and a desire to punish them in the name of protecting potential future citizens.
You have a legal right to drink as an adult, but women began to be arrested and charged with child endangerment for drinking while pregnant. People who would never walk up to a guy at a bar and say, ''Let me call you a cab,'' felt completely free to walk up to a pregnant woman and say, ''You shouldn't be drinking.''
Q. How pervasive is fetal alcohol syndrome?
A. The C.D.C. says that 0.2 to 1.5 per 1,000 live births in the U.S. are babies born with F.A.S. It's a real syndrome, and I have no question that it exists.
Q. But wouldn't the number of cases be far greater if we didn't have the warnings?
A. Warnings are very effective for people who want to hear them and heed them.
A lot of people said, ''So alcohol is bad, I won't touch it when I'm pregnant, and I'll worry about whether I drank the night I conceived.''
And for those women, giving up alcohol for nine months is not a significant sacrifice.
You could feel good that you'd made a decision to promote the health of your fetus, and it's a sign of how responsible you are.
But the labeling has not had a major impact on the incidence of F.A.S. Chronic alcoholics and heavy binge drinkers, it appears, don't stop drinking because of a warning label.
Q. If strangers feel it's incumbent upon them to intervene when they see pregnant women drinking at bars or parties, why, as you write, are obstetricians uncomfortable taking a more aggressive role with their patients?
A. If you're diagnosed with diabetes, the doctor can say: ''I can send you to a diabetes center with a specialist. You have cancer? I know where to send you. But you have a relapsing chronic alcohol abuse problem? I don't know where to send you. And I am not sure I want to deal with you, because it's relapsing.''
It's very hard to find treatment beds for pregnant women. And women are reluctant to enter treatment, because they have to put their other children in foster care and they're not sure they will get them back. It's a big commitment on the part of the patient and the obstetrician.
Q. Your book focuses on one diagnosis. What can we extrapolate from it?
A. Diagnoses are developed in a cultural framework and their meanings change.
What is important to think about is how we understand a diagnosis, not just from a medical point of view but as a culture that has to respond to people with that diagnosis.
And that's true whether you have H.I.V. or diabetes or autism. F.A.S., for example, has gone from, ''Oh, look, a scientific discovery!'' to being a marker of bad mothering. And that still hasn't led to the creation of new and better services.
Q. Despite the absolutism of the warning labels, do scientists still disagree about what constitutes an unacceptable level of alcohol during pregnancy?
A. My sense is that some researchers see risks at moderate levels of exposure and others say you have to have a significantly high level of exposure.
But underlying that is the methodology: you're asking women to recall how much they drank while pregnant. They may not be telling the truth, they may not recall, they may not reveal their illegal drug use as well, and other factors that compromise fetal health.
It's not easy research to conduct. It's easy to control the amount of alcohol you give a pregnant rat.
Q. After six years of researching fetal alcohol syndrome, do you now have a gut instinct about whether it's O.K. to drink during pregnancy?
A. I've read so many different arguments from so many different scientists that I don't think I should comment.
But in a litigious society, one that is committed to banishing all risk, then you have take a position against all drinking.
In theory, anyone could be a terrorist, so everyone has to go through the line at the airport. Whereas in more practical terms, we might be able to develop a profile and only screen certain passengers, but we won't do that.
So everyone has to get their luggage X-rayed.
A CONVERSATION WITH: JANET GOLDEN"