Sughashini Murugesu
Michael Frowen Essay Prize Competition 2011
Michael Frowen Memorial Essay Prize
Competition 2011
“Is Drinking Alcohol During
Pregnancy a Form of Child Abuse?”
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Sughashini Murugesu
Michael Frowen Essay Prize Competition 2011
Contents
Essay...…………………………………………………………………………………………3
References……………………………………………………………………………………10
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Sughashini Murugesu
Michael Frowen Essay Prize Competition 2011
1. Introduction
As a direct consequence of a pregnant woman drinking a certain quantity of alcohol, the
developing child will acquire birth defects in utero. This may be viewed as child abuse:
damage to a child caused by a mother’s neglect. Alcohol is a common drug abused by women
of childbearing age. Infants born to alcoholic mothers may demonstrate prenatal and
postnatal growth deficiency, congenital abnormalities, mental retardation and behavioural
disorders, all known as Fetal Alcohol Syndrome (FAS). This is one of the leading known
preventable causes of mental retardation and birth defects1.
This essay will explore the mechanism by which alcohol impacts child development and
whether this can be truly quantified. Once the theories purported by scientific research have
been discussed, the ethical core of the question will be considered. Much of the debate on this
issue lies in the argument about at which point during pregnancy the fetus can be considered
a ‘child’ susceptible to abuse. There is also the question of whether protection of this ‘child’
can be carried out while respecting a woman’s autonomy. Finally, this essay will consider
ways in which prevention of alcohol-induced defects can be achieved.
2. Effects of Alcohol on Embryonic and Fetal Development
Alcohol is a teratogen capable of interfering with fetal development and causing birth
defects2-3. To diagnose a child with FAS, the child must have all three findings: characteristic
facial abnormalities, growth deficits and central nervous system abnormalities4. The hallmark
of FAS is the array of craniofacial abnormalities; including a long flat philtrum, low nasal
bridge, short palpebral fissures, thin upper lip, ear malformations, flattened maxilla, short
upturned nose, and epicanthal folds5-6.The clinical presentation of FAS related nervous
system abnormalities include developmental delay, microcephaly, seizures, hyperactivity,
cognitive deficits, learning and memory impairments, poor psychosocial functioning and
motor coordination deficits7. A broad range of these symptoms are observed at varying
degrees of severity and in various combinations. Alcohol entering the mother’s bloodstream
does not bind to any tissue or plasma proteins. Hence, it is able to freely cross the placenta,
enter the growing fetus through the umbilical cord and cross the blood brain barrier8. At
various points during development once a specific threshold of alcohol consumption has been
crossed, damaging long term effects are inevitable.
2.1 Mechanism of Alcohol Effect
Alcohol is able to induce craniofacial abnormalities by interfering with neural crest
maintenance and migration9. The exact mechanisms by which this occurs are unknown, but
ethanol has been shown to induce cell damage by increasing reactive oxygen intermediates1013
. Other evidence, using both in vitro and in vivo rodent models highlights the significant,
yet variable, effects of alcohol on neurogenesis. A reduction in stem cell number, increase in
neuronal proliferation, delayed neuronal differentiation and decreased genomic stability14
have been observed. These changes were demonstrated to be in part due to the effect of
ethanol on cytokine release, which propel angiogenesis and neural growth15. Key signalling
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Sughashini Murugesu
Michael Frowen Essay Prize Competition 2011
pathways are altered by exposure to alcohol, including the Wnt-catenin signalling pathway16,
which is an important regulator of stem cell self-renewal in the developing brain17.
Neurotransmitter pathways are also affected, such as the serotonergic 5-hydroxytryptamine
(HT) pathway. This is significant as serotonin is a trophic factor for brain development, the
levels of which are greatly reduced in an ethanol-exposed fetus18-19 possibly contributing to
the abnormal development of the central nervous system in FAS20.
2.2 Impact of Alcohol on Early Pregnancy
It is during embryonic development in the first trimester of pregnancy that the developing
child is most at risk of damage by teratogens, as organogenesis is taking place. The embryo is
most susceptible to teratogenic agents during periods of rapid differentiation, which varies
with each organ (Fig.1). For instance, the critical period for brain growth and development is
from three to 16 weeks. The brain is unusual in that its differentiation continues to extend
into infancy with increasing vascularisation21. Therefore, throughout gestation the brain may
receive increasing quantities of alcohol, which compromises the developing central nervous
system – making it more susceptible to the teratogenic effects of alcohol22. Teratogens can
produce mental retardation during both embryonic and fetal periods. Alcohol exposure will
have the greatest impact during the embryonic stage in the first few months of pregnancy, a
point at which many women may not be aware they are pregnant. Hence such women may
continue drinking heavily, thereby putting their developing child at risk of FAS and other
congenital malformations.
Figure 1.
Time-line of in
utero
development
indicating
periods where
specific organs
and systems are
particularly
susceptible to
teratogenic
damage.
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Sughashini Murugesu
Michael Frowen Essay Prize Competition 2011
2.3
2.3 How Much Alcohol is Too Much?
The quantity and pattern of alcohol consumption during pregnancy has a role to play in the
incidence of FAS. Damage to the development of the child in utero is more likely to occur
following continuous heavy intake of alcohol during pregnancy23-25. A recent study explored
a range of pregnancies, based on a large sample from the millennium cohort study26. It was
shown that children whose mothers had been ‘binge or heavy drinkers’ (seven or more units a
week or six at one sitting) were more likely to be hyperactive and have behavioural and
emotional problems than those whose mothers abstained during pregnancy. However, there
was no evidence to suggest that the children of ‘light drinkers’ (one to two units per week)
had been in any way harmed26. This study clearly demonstrates that alcohol during pregnancy
does not definitively lead to birth defects and thus cannot necessarily be deemed child abuse.
The findings support a woman’s right to choose ‘light’ alcohol consumption during
pregnancy.
The risk of alcohol-related birth defects increases as a direct consequence of various factors
(fig. 2); including increased maternal age, parity, history of alcohol abuse, poverty, smoking,
drug use, nutritional deficiencies and poor prenatal care27. Genetic influences have also been
shown to alter the susceptibility to alcohol teratogenesis. For example, women with a more
efficient alcohol dehydrogenase enzyme and cytochrome P450 2E1 have a decreased risk for
giving birth to a child with FAS28-29. Therefore, the limit at which alcohol cause fetal
malformations is difficult to set due to the individual nature of one’s susceptibility to alcoholinduced birth defects.
Figure 2. Summary of the
interactions of maternal risk
factors and mechanisms
related to FAS and alcoholrelated birth defects.
Circles = Sociobehavioral
factors: alcohol intake
pattern, low socioeconomic
status, culture and smoking.
Squares = Biological
factors: blood alcohol levels,
tobacco components,
undernutrition, free radicals,
hypoxia and cell damage.
Solid lines: biological
relationships and
physiological pathways.
Dotted lines: interactions
among environmental and
behavioural factors.
GI = Gastrointestinal [Abel
and Hannigan,1995].
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Sughashini Murugesu
Michael Frowen Essay Prize Competition 2011
3. Potential Benefits of Alcohol Consumption during Pregnancy
It may be argued that a small quantity of alcohol consumed by the mother may in fact be
beneficial to the developing baby. If alcohol has the potential to reduce stress in mothers, it
may protect the baby from the harmful risk factors associated with stressed mothers. The
physical symptoms associated with stress include an increased heart rate, blood pressure and
muscle tension. During pregnancy stress may increase the risk of preterm labours, low birthweights and complications such as preeclampsia30-31. The results of research investigating the
effect of stress during pregnancy do not appear to be conclusive. The timing of prenatal
maternal exposure to stressful life events has a role to play in the severity of adverse
pregnancy outcomes32. Stress is a highly subjective experience; there are differences in what
an individual would consider stressful and the physiological response is variable.
The question then arises over the effectiveness of alcohol in relieving a pregnant woman’s
stress, both psychologically and, somewhat more importantly to the baby’s development,
physiologically. Research findings have been contradictory; perhaps the most common
conclusion is that alcohol’s effects on stress are complex33. It is clear that there are individual
differences in the effects of alcohol on stress responses. Characteristics influencing this
include a family history of alcoholism, personality traits, level of cognitive functioning, and
gender. Some argue that the adverse associations between stress and health are actually a
consequence of external reactions to stress rather than a direct result of stress itself. For
instance, common reactions to stress include smoking, drinking (alcohol and coffee),
skipping meals or eating junk food, not taking enough physical exercise or getting enough
sleep. In many of the studies, these lifestyle responses to stress are not appropriately
controlled for. Therefore, the debate lies in whether the adverse risks of stress, which can be
dampened by alcohol, outweigh the unquantified variable risk of ‘moderate’ alcohol to the
developing child. It is clear that there are no definitive answers to this, and the nature of the
questions asked involve so many variables it has thus far proven difficult to address
adequately.
4. Child Abuse
Child abuse is any form of physical, emotional or sexual mistreatment or neglect that leads to
injury or harm. Drinking alcohol to the point of hindering development during pregnancy
would fit into the category of neglect. Neglect is the persistent failure to meet a child’s basic
physical and/or psychological needs, likely to result in the serious impairment of the child’s
health or development. Birth defects caused by alcohol-exposure may also be considered
physical abuse due to poisoning causing disfigurement and disability. However, this does not
translate to all instances of alcohol consumption during pregnancy, as discussed earlier birth
defects arise dependent on quantity of alcohol, timing and the individual physiology and
genetics of the mother.
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Michael Frowen Essay Prize Competition 2011
4.1 Philosophical Views on the Nature and Status of the Embryo
As discussed, much of the damage done by alcohol is when it acts as a teratogen during
embryogenesis. Therefore, the controversial status of the embryo and whether it is to be
considered a child susceptible to abuse and in need of protection must be considered when
answering this question. There are a range of moral positions on the status of the embryo
defined. The two most opposite positions are clear, simple and unambiguous. In the first case,
a fertilised egg is regarded as a human being. Consequently, in principle an embryo has an
inviolable value and a right to life. This position would consider that in principle termination
of pregnancy would be unacceptable. Therefore, from this viewpoint it is clear that drinking
during pregnancy at any point is a form of child abuse and thus any sexually active woman of
child bearing age, potentially pregnant, must not drink due to the risk of embryo neglect.
The polar opposite moral standpoint is that the embryo is considered to have very little or no
intrinsic moral value. Hence, it is not considered to need any particular protection, nor is it
regarded as having a right to life. Many people hold a gradualist position somewhere between
the described polar views of embryo status. With regard to the right to life or right to develop,
a range of opinions may be held. These different positions are supported by various
arguments based on, amongst other things, biology, potential, and personhood. Dependent on
one’s opinion on the status of an embryo, the view of alcohol consumption during pregnancy
will vary, as will the conviction of the need to protect the embryo from the risks of alcohol,
thus removing a woman’s right to drink alcohol in certain circumstances.
4.2 Legal Rights of an Unborn Child versus a Mother’s Right to Choose
A principle laid down in the United Nations 1959 Declaration of the Rights of the Child that
the child "needs special safeguards and care, including appropriate legal protection, before as
well as after birth." In accordance with this the Unborn Victims of Violence Act of 2004 is a
United States law which recognizes a "child in utero" as a legal victim. The law defines
"child in utero" as "a member of the species Homo sapiens, at any stage of development, who
is carried in the womb”. If the embryo/fetus were to be considered a ‘child’ then excess
alcohol exposure would most certainly be considered a form of child abuse as reflected in the
laws surrounding alcohol consumption by children. The legal age for purchasing alcohol
being 18 in Great Britain, the same age one is no longer even considered a child legally. The
Unborn Victims of Violence Act was strongly opposed by most pro-choice organizations, on
grounds that the U.S. Supreme Court's Roe v. Wade decision said that the human fetus is not
a "person" under the Fourteenth Amendment to the Constitution, and does not have a
constitutional right to life. Thus the moral dilemma concerning embryo and fetal status has
been played out in the court of law. A law to protect the developing child from alcohol during
pregnancy would cause a similar conflict.
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Michael Frowen Essay Prize Competition 2011
In Great Britain, the Abortion Act of 1967 made abortions legal up to 28 weeks. Therefore, if
it is possible to abort a pregnancy up until a certain point based purely on a woman’s right to
choose, then up until this point it is difficult to consider in the eyes of the Law that drinking
alcohol is a form of child abuse. Undoubtedly after this set point the birth defects resulting
from alcohol is abuse. Yet by this time in the vast majority of FAS cases the damage will
have been done. In order to protect a child from FAS, action has to be taken from the offset,
yet this would be very difficult to justify legally enforcing, considering for much of
pregnancy a woman very much holds the rights to treat her own body as she wishes. All
women of reproductive age who are sexually active, not using effective birth control, and
who consume alcohol are at risk of having a child with FAS. If taken to the extreme, all
women of child bearing-age would be scrutinised for drinking alcohol.
5. Current Government Advice to Women
The Department of Health advises “Pregnant women and women trying to conceive should
avoid alcohol altogether, never more than 1– 2 units once or twice a week.” In March 2008
National Institute for Health and Clinical Excellence (NICE) published guidance advising
women not to drink at all during the first three months of pregnancy, adding that a small
amount of alcohol one or two days a week after the first trimester was safe34. It appears there
is almost conflicting advice from the government wanting women to abstain from drinking in
order to reduce risks to the developing child as much as possible, yet only having strong
evidence that heavy drinking is damaging – they settle for an upper limit of alcohol
consumption for the pregnant woman. A 2007 report found that almost one in 10 pregnant
women were regularly exceeding the recommended amounts35. The government is uncertain
about the precise impact of small amounts of alcohol on unborn babies and has concerns for
women pushing the boundaries of ‘light’ drinking. Therefore, they are encouraging the
undoubtedly safe choice of complete abstinence from alcohol during pregnancy.
6. Protecting Pregnancies from Alcohol Abuse
Prevention is the key way of solving the adverse effects of alcohol in pregnancy. The current
government advice discussed above is a type of primary prevention, aiming to avert the
health problem across the population before FAS occurs. Methods to improve the public’s
knowledge include employing the media, public service announcements, advertising and a
warning label on the alcoholic beverage itself. These methods have been shown to increase
awareness of the dangers of alcohol consumption during pregnancy to an extent, which may
lead to a decrease in FAS incidence. Secondary prevention involves identifying persons at
risk, so strategies involve screening and early intervention programs for pregnant women and
women of child-bearing age who may be at risk of having a child with FAS. Some screening
methods currently in use are CAGE, T-ACE and TWEAK36, questionnaires designed to
identify at-risk drinkers. Tertiary prevention narrows the target group further to those with a
recurrence of the condition and attempts to lessen the cognitive, behavioural and social
impact of alcohol exposure during child development. Early detection of FAS, although
difficult37, is necessary since proper care early in a child’s life can reduce the severity of
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Michael Frowen Essay Prize Competition 2011
impairments. Programs need to appropriately diagnose children suffering birth defects as a
consequence of alcohol and help these children and their families.
A number of treatment programs targeting at-risk women have shown positive results, one
such example is the ‘Seattle Birth to 3 Advocacy Project’38-39. This program was designed for
women, who were heavy substance abusers, had no prenatal care and were not connected to
service providers during their pregnancy. Specially trained paraprofessionals worked closely
with the women, showing them how to set goals, connect with services and acquire new
skills. After two years, the majority had remained abstinent from alcohol and importantly
were using long-term birth control methods, thereby reducing the risk of alcohol-exposed
pregnancies. These results and other similar projects e.g. ‘Trial for Early Alcohol Treatment’
and ‘Protecting the Next Pregnancy’, demonstrate the effectiveness of measures targeting
high-risk women for the prevention of FAS. Much responsibility lies with health
professionals, including medical practitioners, alcohol teams and probation services, to
appropriately inform women at risk, and to initiate referrals and early interventions to protect
the potential child from a FAS outcome.
7. Conclusion
In conclusion, it is clear that knowingly drinking excess alcohol during pregnancy causing
birth defects is a form of child abuse. The problem lies in defining the safe limits of alcohol
for those women who want to continue drinking during pregnancy. It is difficult to determine
the advantages of light drinking during pregnancy but ultimately it would be a woman’s right
to choose if no direct harm to the child can be demonstrated. A key problem lies in the fact
that many women are initially unaware of their pregnancy and thus they continue drinking to
a harmful degree unintentionally; unfortunately in some cases by the time the developing
child is recognised the damage is done. Defining alcohol during pregnancy as child abuse is
dependent on one’s definition of a child. The future challenge is to reduce the incidence of
harmful alcohol consumption during pregnancy. By increasing public knowledge of the facts
and isolating at-risk cases efficiently, some children may be saved from alcohol-induced birth
defects.
Word count: 2934
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Michael Frowen Essay Prize Competition 2011
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