205: A Historical Perspective on Alcohol in Pregnancy

205 screenshot

When viewed through our 21st century eyes, it does seem as though our pregnant heroine is drinking an awful lot of alcohol.

Throughout history, alcohol was not always thought to be something to avoid in pregnancy.  Alcohol was often medicine – whisky for colds or laryngitis, hot brandy punch for cholera, rum-soaked cherries for a cold.  Doctors prescribed champagne as a treatment for morning sickness. Pregnant women in labor would take a shot or two of liquor to ease their discomfort. Wine was often recommended during pregnancy to help pregnant women relax.

beehive-brandy

General opinion maintained that alcohol was not dangerous in pregnancy, though throughout the years, some have voiced concern. Aristotle is quoted to have warned against the hazard of drinking during pregnancy, “foolish, drunken, and harebrained women most often bring forth children like unto themselves, morose and languid.”  In 1899, English physician William Sullivan noted that among his patients in a Liverpool prison, stillbirth rates were 250% higher for his alcoholic female prisoners than for their sober counterparts. He also noted that the children of women with no (or limited) access to alcohol during pregnancy were healthier, leading him to hypothesize, “a direct toxic action on the embryo, owing to continued excesses during pregnancy.”

In an issue of the Quarterly Journal of Inebriety published the same year, an editorial contended, “habitual intemperance on the part of the female when pregnant must tend to impair the development of the fetus in utero by impairing cell growth. What we know now is that maternal use of alcohol during pregnancy can have deleterious effects on the growing fetus and lead to a number of problems.”  Many other physicians observed and reported similar findings in the 19th and early 20th century, describing outcomes that would later come to be recognized as symptoms of Fetal Alcohol Syndrome.

slides_196parents600
World’s and National Woman’s Christian Temperance Union, 1914   source

It seems, though, that as soon as prohibition ended in the US, attitudes regarding alcohol in pregnancy shifted again, and public discussion of the risk and medical research on the question, seemed to disappear.  The medical community seemed to turn direction completely, with a statement in 1953 in Clinical Obstetrics stating, “alcohol, as such, is not injurious and need not be eliminated during pregnancy.”   As recently as the 1960s-1980s in the US, alcohol was given intravenously to women in preterm labor as a tocolytic – a medication to stop uterine contractions calm and halt preterm labor.

A fetus is vulnerable to alcohol particularly because alcohol crosses the placenta, yet the fetus has lower levels of the enzyme alcohol dehydrogenase to metabolize the alcohol than does the mother. The fetus is thus exposed to alcohol for a much longer period of time.

The effects of alcohol manifest in different ways depending on the stage of pregnancy. Exposure in the first trimester can lead to characteristic abnormalities in the face as well as devastating heart defects and abnormalities of the bone structure, kidneys, eyes and hearing. Second trimester alcohol exposure increases the risk of miscarriage and stillbirth. In the third trimester, fetal exposure to alcohol affects weight, length and brain growth.

FASkid
By NIH/National Institute on Alcohol Abuse and Alcoholism

Fetal Alcohol Spectrum Disorders are the conditions that may occur in persons who were exposed to alcohol in utero. Problems can include abnormal appearance with characteristic facial abnormalities, short height, low body weight, small head size, poor coordination, low intelligence, behavioral problems and hearing and vision problems. It is thought to affect 2-5% of people in the US and Western Europe. Worldwide incidence is approximately 1 in 2000 live births.

It wasn’t until the 1970s that Fetal Alcohol Syndrome was defined and fully recognized. Work to educate pregnant women of the dangers of alcohol in pregnancy began in earnest after researchers at the University of Washington identified a pattern of abnormalities in infants born to alcoholic mothers.  Animal studies in monkeys then followed that confirmed that alcohol was indeed responsible.  Rather than naming the syndrome after themselves, as is common in the discovery of medical syndromes historically, the University of Washington researchers, Drs Kenneth Lyons Jones and David Weyhe Smith, chose the name Fetal Alcohol Syndrome after the agent responsible for the problem, to raise awareness of the problem alcohol in pregnancy.

1988 brought the Alcoholic Beverage Labeling Act in the US, mandating that the labels of alcoholic beverages carry a government warning.

warning

Today, the official statement from American Congress of Obstetricians and Gynecologists reads:

“Women should avoid alcohol entirely while pregnant or trying to conceive because damage can occur in the earliest weeks of pregnancy, even before a woman knows that she is pregnant.”

Other societies of providers of obstetric care phrase it a bit less stringently, with the European Board and College of Obstetrics and Gynecology advising:

“Based on what is known as well as the continuing uncertainty as to whether any safe consumption threshold exists […] women should ideally abstain from alcohol during pregnancy or when planning pregnancy.”

Similarly, the Royal College of Obstetricians and Gynaecologists in the UK advises:

“If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum. Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the grater the risk. […] The risk of harm to the baby is likely to be low if a woman has drunk only small amounts of alcohol before she knew she was pregnant or during pregnancy.”

Pregnancy in the 18th century was a scary proposition indeed. Reliable records of maternal death in the time are difficult to come by but studies of death records in the UK in the time suggest about 2.5-3% maternal death rate per baptism recorded.  Given an average of 5-6 pregnancies per woman, this would result in 11-16% risk for the average 18th century mother to die in childbirth or shortly after in her lifetime, and perhaps even higher given that the risk subsequent births are not necessarily independent of previous births.  Maybe we can understand why the women of the time (and their concerned partners) would encourage alcohol to help them relax and briefly forget about the fact they may not survive childbirth, especially without knowledge the alcohol would be doing any harm.  Compare this to the current risk of maternal mortality today in the US of 0.019%.

Even with her medical knowledge, Claire is coming from the reference point of the 1940’s when the medical community was of the opinion that alcohol was not hazardous to pregnancy, and actually was considered beneficial.  Seeing these huge shifts in the medical community’s understanding of the risk of alcohol, it makes one wonder what we will come to know in the future as an undeniable risk we assume is healthy today!

camels_doctors_whiteshirt
source

Questions, comments, concerns, or suggestions for future Outlander medicine topics?  I’d love to hear from you!  Leave a comment here or find me on twitter @SassenachDoctor.

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s