Alcohol and Breastfeeding: NHMRC buys into abstinence-only messaging

maggieLast month, I started talking a little bit about alcohol, pregnancy, and abstinence-only messages, in a takedown of one particular study which failed to link alcohol and preterm birth, but said it did. “Bad science on booze in pregnancy: Women infantilised with absolutist messages”

Crikey took on the new abstinence-only NHMRC guidelines today, in “Questions for the NHMRC on behalf of pregnant tipplers”. Excerpted (read the rest):

The guidelines issue a “last drinks” call for women who are either pregnant, planning a pregnancy or breastfeeding, advising them that the safest option is to consume no alcohol at all.

This updates the NHMRC’s 2001 guidelines which told pregnant women: “…if you average less than one drink per day, there will be no measurable impact on the physical and mental development of your child.”

So what new evidence has come to light to cause the NHMRC to change their recommendation?

It may come as a surprise to women wishing to make an informed decision about their alcohol intake, that the NHMRC decision was (in its own words), “not based on the fact that substantial new evidence had emerged since the previous guidelines were published, but on limitations of the existing evidence.”

In other words, the NHMRC found no evidence that low levels of alcohol consumption cause any harms at all during pregnancy. In fact, the research it cites to support its recommendation includes several studies which fail to show any link between low levels of alcohol exposure and birth-related problems.

Don’t get me started on the “pre-pregnant” thing; not today. Moving on to breastfeeding:

The NHMRC guidelines betray their lack of rigorous summarising up front. Not only on the alcohol side of things – in the same breath they say that “Australian and international guidelines recommend breastfeeding for the first six months”! Later in the fine print they mention the “two years” WHO recommendation – but not many people read that deep in a report.

And, here’s the thing – according to my anecdata, the more we say that women are Bad Bad Nasty Evil Mothers for having a glass of wine while breastfeeding, the more women will wean early “because I want to have a drink now and then”. The NHMRC explicitly acknowledges this discouragement effect, on pages 68 and 79 – but they fail to modify their headline guidelines because of it.

The detailed guidelines on how to drink for mothers who do choose to drink while lactating are buried on pages 80 and 81:

Advice for Breastfeeding Mothers

* Not drinking alcohol is the safest option.

* Women should avoid alcohol in the first month after delivery until breastfeeding is well established.

* After that:

– alcohol intake should be limited to no more than two standard drinks a day
– women should avoid drinking immediately before breastfeeding
– women who wish to drink alcohol could consider expressing milk in advance.

There is still a glaring lack of evidence here. Despite numerous studies, we have no evidence that abstinence is any safer than light drinking, nor that having half a glass with a young baby (or more, for an older child) latched on is harmful, though I’d not suggest doing it for every feed. And it’s probably quite a lot safer than juggling an open mug of hot coffee, which I rarely see women copping the stink-eye for.

“Not drinking alcohol is the safest option” is unsupported.

The other problem is that not many people read the fine print. The vast majority will only ever access or read the Summary guidelines, which state, on page 5:

Guideline 4: Pregnancy and breastfeeding

Maternal alcohol consumption can harm the developing fetus or breastfeeding baby.

A For women who are pregnant or planning a pregnancy, not drinking is the safest option.
B For women who are breastfeeding, not drinking is the safest option.

Are you looking for proof that most people won’t access the more nuanced guidelines? Here it is: I can’t find a single reference to any of them in the mainstream media, nor in any of the blogs mentioning these guidelines. Crikey is the sole exception.

Daily Telegraph:

It is now considered unsafe for a pregnant woman to have any alcohol in pregnancy or while breastfeeding.

The Australian:

The nation’s top health advice body today released long-awaited new guidelines on alcohol intake, which also recommended no alcohol at all for children, people under 18, pregnant women and breastfeeding mothers.

The Canberra Times:

And teetotalling is the safest option for young people and women who are pregnant, breastfeeding or trying to have a baby, according to new guidelines that ”usher in a new era of caution” about alcohol.

The Age:

Young people are now advised not to drink at all — as are women who are pregnant, planning to be pregnant or breast feeding.

LiveNews:

The guidelines also advise people under 18 not to drink and for pregnant and breast feeding women to stay away from alcohol.

The ABC:

The Council advises people under 18, and pregnant and breastfeeding women, not to drink at all.

SMH:

In a departure from previous advice, the guidelines also recommend that pregnant and breastfeeding women and people under the age of 18 should drink no alcohol at all.

You know, our mummy-brains really can process complex information in the first instance. Even if journalists choose not to. (Yes, I crossed out “can’t”.)

If you’d like to play along at home, ask your midwife, child health nurse, GP or obstetrician whether she’s read the guidelines, and what they say about breastfeeding and alcohol. Report back here!

In the meantime, I can’t help but recommend to breastfeeding women, particularly women in already marginalised groups: educate yourself, and think hard before disclosing informed light alcohol intake to healthcare staff. Unless you want this to go on your medical record, and risk being treated as an abusive mother.

[image is of Ramona and Maggie Gyllenhaal breastfeeding. I particularly like this shot because it isn’t the usual breastfeeding image: a soft-focus shot of the mother of a tiny baby nursing in private, eyes locked on each other, no other people around, often in a nightgown. Maggie’s just going about her life.]



Categories: culture wars, education, ethics & philosophy, gender & feminism, health, Science

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15 replies

  1. *sigh* pre-pregnant. Sod that. Are we meant to be perfectly ready to have a child at any moment? Should I have started taking folic supplements at 17 when I first *could* get pregnant? Nevermind that many of us are here because our parents had a bit of a drink at a party one night and forgot to take precautions..!

  2. Thanks for an informed article.
    I too am somewhat distressed at the concept of “pre-pregnant.”
    ps to MsLaurie: I totally read that as “frolic supplements.”

  3. Frolic supplements would be brilliant!

  4. While I totally agree with you about this (and did drink while pregnant and breastfeeding – my obstetrician put in bold type “one drink a day is OK” in his single page information sheet – I did notice an example of infantilising that wasn’t about pregnant women – but about alchohol.
    I don’t know if you noticed that the safe drinking guidelines for adults have changed again – they reduced the recommendation for men from 4 a day to 2 a day. The reason? Lots of people were saving up the 4 a day for the weekend, and didn’t read the fine print saying that binge drinking was unsafe.
    I think alcohol does bring out the infantilising in a government body.

  5. *sigh*
    Nope, the pre-pregnancy thing gets me in an uproar too. We should always walk around as if we could be impregnated at any moment, ya know.
    When I was breastfeeding if I dared to have a glass of wine w/ friends around there was always one who would make a huge deal out of it, and inform me that “if you are going to drink then I am not, b/c I think it is wrong”. I don’t know why I let the guilt shame me out of a single glass. If she didn’t want to drink, her choice. Ahh, but I was so young…
    OuyangDan’s last blog post..Always brush your teeth b/f you leave the house…

  6. Really good post. I think you’ve raised such an important discussion here.

  7. Good discussion. All the points raised are part of a very complex decision process.
    I don’t pretend to understand the drinking habits of other people, but I do try to give midwifery/breastfeeding advice that is based on evidence where possible. The truth is that noone knows the safe level of alcohol, or aspirin, or a whole lot of other substances. When a new drug is introduced, it goes through lots of clinical trials. But you can’t do clinical trials on alcohol and pregnant women – it would be considered unethical.
    If the NHMRC guidelines give ‘permission’ for a particular drinking regime, and someone follows that carefully – documenting all the way &c, then has a child with fetal alcohol syndrome, the NHMRC can expect to be sued.
    There are many defensive protocols in maternity care. Women who want vaginal birth after caesarean (vbac) are ‘required’ to have IV cannulas and continuous fetal monitoring in active labour, even though the likelihood of these being needed is very small. The monitoring requirements may actually interfere with the woman’s progress towards a vaginal birth, which is what SHE wants, but the system is protecting her against the risk as their risk management experts perceive it. Women whose labours are interrupted by whatever the interruption happens to be are then told they are taking too long and need to be augmented.
    I heard that milk banks in Germany used to do the smell test to decide which donations had a bit too much grog in them.
    Joy Johnston’s last blog post..A blog worth reading

  8. The truth is that noone knows the safe level of alcohol, or aspirin, or a whole lot of other substances. When a new drug is introduced, it goes through lots of clinical trials. But you can’t do clinical trials on alcohol and pregnant women – it would be considered unethical.

    You can’t do an interventional placebo-controlled trial, but very large-scale observational studies are done, and these do produce useful results – but only if you dig beneath the headline. This one, for example.
    There have been interventional as well as observational studies on alcohol in breastfeeding. Kellymom has a few good links/cites.

    If the NHMRC guidelines give ‘permission’ for a particular drinking regime, and someone follows that carefully – documenting all the way &c, then has a child with fetal alcohol syndrome, the NHMRC can expect to be sued.

    I think a successful case is vanishingly unlikely. Is there any precedent?
    Your examples of supposedly-“defensive” maternity care are excellent examples of women being controlled and infantilised in pursuit of aims that are not necessarily safety-related at all.

  9. “I think a successful case is vanishingly unlikely. ”
    Unfortunately I think that’s the point. I don’t know of any precedent.
    “Your examples of supposedly-”defensive” maternity care are excellent examples of women being controlled and infantilised in pursuit of aims that are not necessarily safety-related at all.”
    Thankyou. Which brings us back to the Maternity Services Review. Many women who really do want a good chance at vbac choose an independent midwife who knows how to work in harmony with the natural processes, and will advise on an individual basis, rather than the broad brush compliance that is expected in other maternity services. According to the recommendations of the Review, midwives who are employed directly by women should not be able to continue practice. The Review sees no reason for the government to provide us with indemnity in the way that they provide indemnity support for obstetricians and procedural GPs.
    Joy Johnston’s last blog post..A blog worth reading

  10. We are considering maybe, possibly that we might (can you tell I’m a bit undecided!) start trying for a baby soonish, and I am finding these posts incredibly helpful. I know this stuff will come up in later discussions and he will be sent here for reading before we discuss! So thank you.

  11. While I agree with you in regards to breastfeeding, I find the alcohol and pregnancy issue problematic. From what I have gathered, the exact point in fetal development when a bit of alcohol *can* cause FAS or other issues is not known. Therefore, its really not wise to play with fire. Who knows when it is relatively safe to have a small drink and when it could cause major damage? I am firmly in the no alcohol while pregnant camp for that reason and that reason only.
    As for the “prepregnant” thing, I think it is referring to people who are knowingly either preparing to ttc or are in the process of actually ttc. I don’t have a problem with this. No, all women of childbearing age should not be expected to live like they may get pregnant at any moment … but the ones who *are* planning to might be well advised to avoid certain things, take folic acid, etc depending on their own informed choices.
    I’m not sure this post was as coherent as it should be. I’m tired. Apologies if I rambled too much.

  12. In the USA, my homebirth midwife handed me a list of scenarios that she would use to limit patients from homebirth. Drinking any alcohol during pregnancy was one of her guidelines. Bah! I wanted to toss the Kitzinger pregnancy book from her shelf right into her lap (with its’ “European outlook”. Instead, I chose to do what you suggest – not mention occasional light drinking during my pregnancy. Sometimes, when my family and I are in a restaurant and I sneak a sip of my husband’s beer, I feel like some sort of criminal. I feel very angry about this issue!

  13. Fantastic information!
    Thanks.
    Jay

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