"Drinking alcohol early in pregnancy, even in small amounts, increases the risk of harming your baby," reports The Independent, one of several news outlets to report on the latest study on the risks of drinking during pregnancy.
The study of 1,303 pregnant women aged between 18 and 45 years old found that women who drank less than two units a week during the first 12 weeks of pregnancy were at increased risk of complications, including premature birth.
While the risk at the individual level is still low, researchers from the University of Leeds concluded that the first trimester was the most "vulnerable period" of a woman's pregnancy.
They also found a more general association between drinking alcohol throughout pregnancy and worse birth outcomes, such as lower birth weight or foetal growth restriction.
"Our results highlight the need for endorsing the abstinence-only message, and further illuminate how timing of exposure is important in the association of alcohol with birth outcomes," say the study's authors.
The study, published in the Journal of Epidemiology and Community Health, suggests that women who are planning to conceive and who are pregnant should abstain from alcohol.
However, for now it is unclear whether consideration of this study alongside other evidence will lead to a change to government recommendations on drinking during pregnancy.
There currently remains some uncertainty around whether there is a safe level of alcohol consumption during pregnancy, or whether it should be avoided altogether.
The Department of Health recommends that pregnant women and women trying to conceive should avoid alcohol completely, and, if they choose to drink, should never drink more than one to two units once or twice a week and never get drunk.
The most recent National Institute for Health and Care Excellence (NICE) guidance on Antenatal Care (2008) specifically advises that women trying to conceive, and those in the first three months of pregnancy, should avoid drinking alcohol, as this may be associated with an increased risk of miscarriage.
Where did the story come from?
The study was carried out by researchers from the University of Leeds and was funded by the Food Standards Agency. It was published in the peer-reviewed Journal of Epidemiology and Community Health.
The results of the research were well reported by BBC News and The Independent. The Daily Telegraph's headline about "middle-class mothers' alcohol risk to babies" was based on the finding that women reporting alcohol intake above two units per week were more likely to be older, have a university degree, be of European origin, and were less likely to live in a deprived area.
However, the researchers did not conclude that "middle-class mothers are at greater risk of having premature and smaller babies as they drink too much in pregnancy", as the paper reports.
What kind of research was this?
This was a prospective cohort study carried out in Leeds that aimed to determine the association between alcohol intake before and during pregnancy with birth weight and gestational age.
It also aimed to examine whether there was a different effect depending on the timing of exposure during pregnancy.
There currently remains some uncertainty around whether there is a safe level of alcohol consumption during pregnancy or whether it should be avoided altogether.
Cohort studies are the ideal study design to address this question. However, despite the fact that the researchers adjusted for a number of confounders, it is possible there are other factors that explain the association seen in the research.
What did the research involve?
The researchers studied 1,303 pregnant women aged between 18 and 45 years old.
The women were asked about their alcohol consumption using food frequency questionnaires. The women completed the questionnaire three times:
- when they were enrolled into the study – they were asked about consumption from 4 weeks prior to pregnancy through to week 12 of pregnancy
- at week 28 of pregnancy – they were asked about consumption between weeks 13 and 28 of pregnancy
- after they had given birth – they were asked about consumption between weeks 29 and 40 of pregnancy
The reported frequency and type of alcohol drunk was used to calculate the units consumed per week.
Based on their responses, women were categorised as non-drinking, drinking two or fewer units per week, or drinking more than two units per week.
Birth outcomes were obtained from hospital maternal records. The primary outcome was birthweight, but the researchers also looked at birth centiles (birth size compared with other babies, adjusted for maternal height, weight, ethnicity, how many children she had, and the birthweight and gender of the baby), premature birth (before 37 weeks of gestation) and babies being small for gestational age (below the 10th growth centile).
The researchers then looked at the association between drinking status and birth outcomes. They adjusted for confounders that included the mother's salivary cotinine (a biomarker of smoking status), pre-pregnancy weight, height, age, ethnicity, how many children she had, caffeine intake, and education.
What were the basic results?
Approximately three-quarters of women before pregnancy and more than half in the first trimester reported alcohol intakes of more than two units per week.
Just over a quarter of women reported drinking more than two units per week in the second or third trimester.
Alcohol consumption four weeks before pregnancy
Drinking more than two units per week four weeks before pregnancy was associated with lower birthweight (105.7g lower) and a 7.7 decrease in birth centile compared with not drinking. Drinking less than two units was not associated with lower birthweight or birth centile compared with not drinking.
Alcohol consumption during the first trimester of pregnancy
Drinking more than two units per week during the first trimester of pregnancy was associated with an approximate 100g reduction in birthweight and an 8.2 decrease in birth centile compared with not drinking.
Drinking more than two units per week was associated with increased odds of having a baby small for its gestational age (odds ratio (OR) 2.0, 95% confidence interval (CI) 1.2 to 3.4) and a premature birth (OR 3.5, 95% CI 1.1 to 11.2).
Drinking two units or less per week during the first trimester of pregnancy was associated with an approximate 100g reduction in birthweight and a 5.8 decrease in birth centile compared with not drinking. Drinking two units or less per week was also associated with increased odds of having a preterm birth (OR 4.6, 95% CI 1.4 to 14.7).
Alcohol consumption during the second and third trimesters of pregnancy
Drinking more than two units per week during the second trimester of pregnancy was associated with an approximate 100g reduction in birthweight, and during the third trimester of pregnancy was associated with an approximate 50g reduction in birthweight compared with not drinking.
How did the researchers interpret the results?
The researchers concluded that, "Maternal alcohol intake during the first trimester was found to have the strongest association with foetal growth and gestational age. Women who adhered to guidelines in this period were still at increased risk of adverse birth outcomes even after adjustment for known risk factors.
"Maternal alcohol intakes which exceeded the recommendations in the period leading up to pregnancy were also found to be associated with foetal growth, suggesting that the [period around conception] could be particularly sensitive to the effects of alcohol on the foetus.
"Our results highlight the need for endorsing the abstinence-only message, and further illuminate how timing of exposure is important in the association of alcohol with birth outcomes, with the first trimester being the most vulnerable period."
Conclusion
This cohort study suggests that women who are planning to conceive and who are pregnant should abstain from alcohol. Drinking more than two units of alcohol per week was associated with adverse birth outcomes in all trimesters.
In addition, the study found that women who reported limiting drinking to less than two units per week during the first trimester of pregnancy were also at increased risk of adverse birth outcomes.
This study has the strength that it associated alcohol intake at three time points, covering different periods of pregnancy. Alcohol intake was assessed during pregnancy and not after birth, reducing the possibility of recall bias. In addition, it adjusted for a number of confounders and used an objective measure of smoking.
However, the study was originally designed to assess the impact of caffeine intake on birth outcomes. Alcohol intake was self-reported, and there is the possibility of under-reporting. Few women had data on alcohol consumption in the third trimester (30% of the original cohort).
Also, despite the fact that the researchers adjusted for a number of confounders, it is possible there are other factors that explain the association seen.
This research provides further evidence for not drinking during pregnancy. However, for now it is unclear whether consideration of this study alongside other evidence will lead to a change in NICE or Department of Health recommendations around alcohol use during pregnancy.
In the UK, the Department of Health currently recommends that pregnant women and women trying to conceive should avoid alcohol altogether, and, if they choose to drink, should never drink more than one to two units once or twice a week, and never get drunk.
The most recent NICE guidance on Antenatal Care (2008) specifically advises that women trying to conceive, and those in the first three months of pregnancy, should avoid drinking alcohol, as this may be associated with an increased risk of miscarriage.
After this, if women choose to drink during pregnancy they should drink no more than one to two units once or twice a week. NICE says that, "Although there is uncertainty regarding a safe level of alcohol consumption in pregnancy, at this low level there is no evidence of harm to the unborn baby."
The organisation advises that getting drunk or binge drinking should be avoided throughout pregnancy, as this may be harmful to the unborn baby.
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