Should advice about drinking during pregnancy really be left up to individual physicians??

Drinking alcohol during pregnancy has been in the news over the past few weeks, partly due to recent photos of actress Kate Hudson drinking a glass of red wine while on vacation and pregnant with her second child.

The Huffington Post published an article last week called Alcohol During Pregnancy: How Dangerous Is It Really? (Catherine Pearson, April 11, 2011). The journalist interviews two physicians, Dr. Ricki Pollycove, an OBGYN and HuffPost Health contributor, and Dr. Amos Grunebaum, director of Obstetrics at Cornell University’s Medical Center.

In the interviews, both physicians state that no drinking during pregnancy is best and that this perspective matches current clinical best practices. However, they both seemed pretty comfortable with condoning occasional drinking in the later stages of pregnancy.

Pollycove is quoted as saying: “Later on in your pregnancy — and a good marker here is about the halfway mark or 20 weeks — it’s really not injurious in the same potentially catastrophic way. I tell my patients, ‘If you’re going to someone’s wedding, enjoy it! You can have a glass of champagne.'”

Grunebaum is quoted as saying: “Of course, the safest thing is to drink no alcohol at all. That is the only way to completely eliminate the risk of FAS. But I take care of a lot of European patients, and it is very acceptable in Europe to occasionally drink a glass of wine.”

The article concludes with a comment on how the decision to drink during pregnancy should be decided by individual women in consultation with their physicians.

Discussions with pregnant women (and all women really) about alcohol use is very important and health care providers should strive to create an environment in which women feel comfortable disclosing their alcohol consumption without fear of judgment or a sense of heightened scrutiny. The approach that health care providers take to discussing these issues may indeed vary depending on where a women is at in her life, e.g., was the pregnancy planned, what is the role of alcohol in her life in general, etc.

However, the idea of individual physicians interpreting clinical guidelines according to their own perspectives on the issue is rather alarming. In this article, these two physicians are portrayed as making allowances for alcohol use later in pregnancy due to ambiguity in the current state of research, because cultural norms in Europe suggest that a glass of wine might be okay (as opposed to beer??), and because women should be able to enjoy events like weddings without feeling deprived. Does this really make sense???

A couple of weeks ago, I mentioned in a post called Understanding the gap between best practices and actual practices the difficulties in ensuring that health care providers have the best evidence available to them to make clinical decisions. When it comes to alcohol during pregnancy, the evidence has been well synthesized and most physicians seem to be aware that “No alcohol during pregnancy is best.” But having the best information available still doesn’t seem to have an impact on clinical practice. What is going on here?

In The paths from research to improved health outcomes (Evid Based Med 2005;10:4-7 doi:10.1136/ebm.10.1.4-a), researchers Glasziou and Haynes describe what they call the “research-to-practice pipeline.” They comment that even after research has been synthesized, health care providers still need to become aware of the research, accept the research, apply the information, have the skill to be able to implement the guidelines, overcome old habits to act on the research, and then support patients in understanding, agreeing with, and adhering with the guidelines. They comment “Medicine aims to provide clinicians and patients with choices about the most effective care based on the best available research evidence. To patients this is a natural expectation. To clinicians this is a near impossible dream.”

In Canada, clinical guidelines on alcohol use during pregnancy have been developed by the Society of Obstetricians and Gynaecologists of Canada and endorsed by the Association of Obstetricians and Gynecologists of Quebec; the Canadian Association of Midwives; the Canadian Association of Perinatal, Women’s Health and Neonatal Nurses (CAPWHN); the College of Family Physicians of Canada; the Federation of Medical Women of Canada; the Society of Rural Physicians of Canada; and Motherisk.

These guidelines assess and synthesize the best available evidence. They state:

  • There is evidence that alcohol consumption in pregnancy can cause fetal harm. There is insufficient evidence regarding fetal safety or harm at low levels of alcohol consumption in pregnancy.
  • There is insufficient evidence to define any threshold for low-level drinking in pregnancy.