Conceiving Risk, Bearing Responsibility: Fetal Alcohol Syndrome and the Diagnosis of Moral Disorder
http://www.100md.com
《新英格兰医药杂志》
Throughout history, pregnant women have been advised and admonished. The 18th-century handbook Rules and Cautions for the Conduct of Pregnant Women counseled pregnant women to avoid "agitation of the body from violent or improper exercise, as jolting in a carriage, riding on horseback, dancing," and "whatever disturbs the body or mind." Restrictions on maternal behavior continued to tighten in the early 20th century and were, more often than not, based on the cultural and social biases of the times. It was not until the latter half of the 20th century that epidemiologic research on the effect of such maternal behavior on birth outcomes led to the relaxing — or, in the case of prenatal physical activity, the reversing — of extant guidelines. This has not been the case, however, for prenatal alcohol consumption. Indeed, guidelines regarding drinking during pregnancy have not changed since the 1981 Surgeon General's report recommending abstinence during pregnancy.
Despite the implications of its title, Elizabeth Armstrong's book aims to reveal the insufficient basis for recommendations regarding maternal alcohol consumption as well as the moral condemnation of pregnant women who do drink. Drinking during pregnancy is not common in the United States. Approximately one in eight women reports having had at least one drink during pregnancy, and, of them, three quarters consume fewer than seven drinks per week. Furthermore, not every woman who drinks during pregnancy will give birth to a child with fetal alcohol syndrome. Even among heavy drinkers, rates of fetal alcohol syndrome are less than 5 percent. Thus, the identification of factors that place particular women at risk is a key issue that, as Armstrong points out, has not been adequately addressed.
Little is known regarding the amounts and patterns of alcohol use that increase risk, the influence of concomitant factors such as drug use, nutritional deficiency, and stress, and the role of genetic susceptibility. Although Armstrong relies heavily on descriptive interview data to make these points, a critique of the original etiologic and epidemiologic studies (sparse though they are) of alcohol and fetal alcohol syndrome would have strengthened her arguments.
Armstrong goes on to claim that the federally mandated labels on alcoholic beverages ("According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects") have directed public attention away from the social inequities that are at the root of poor birth outcomes and toward individual responsibility and blame. Although her advocacy for social change is compelling, it does not preclude the immediate public health need for guidelines at an individual level. The foundation for these guidelines may have gaps, and the mode of their delivery may be flawed, but the need remains nonetheless. As the authors of a review article on fetal alcohol syndrome in the Journal pointed out a quarter-century ago (S.K. Clarren and D.W. Smith. Letter to the editor. 1978;299:556), "a large number of congenital malformations and central-nervous-system dysfunctions will be prevented through maternal avoidance of heavy liquor consumption during pregnancy." The goal for the future should be the further refinement of evidence-based advice for pregnant women — a far cry from an anecdotal "handbook" of admonitions.
Lisa Chasan-Taber, Sc.D.
University of Massachusetts–Amherst
Amherst, MA 01003(By Elizabeth M. Armstrong)
Despite the implications of its title, Elizabeth Armstrong's book aims to reveal the insufficient basis for recommendations regarding maternal alcohol consumption as well as the moral condemnation of pregnant women who do drink. Drinking during pregnancy is not common in the United States. Approximately one in eight women reports having had at least one drink during pregnancy, and, of them, three quarters consume fewer than seven drinks per week. Furthermore, not every woman who drinks during pregnancy will give birth to a child with fetal alcohol syndrome. Even among heavy drinkers, rates of fetal alcohol syndrome are less than 5 percent. Thus, the identification of factors that place particular women at risk is a key issue that, as Armstrong points out, has not been adequately addressed.
Little is known regarding the amounts and patterns of alcohol use that increase risk, the influence of concomitant factors such as drug use, nutritional deficiency, and stress, and the role of genetic susceptibility. Although Armstrong relies heavily on descriptive interview data to make these points, a critique of the original etiologic and epidemiologic studies (sparse though they are) of alcohol and fetal alcohol syndrome would have strengthened her arguments.
Armstrong goes on to claim that the federally mandated labels on alcoholic beverages ("According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects") have directed public attention away from the social inequities that are at the root of poor birth outcomes and toward individual responsibility and blame. Although her advocacy for social change is compelling, it does not preclude the immediate public health need for guidelines at an individual level. The foundation for these guidelines may have gaps, and the mode of their delivery may be flawed, but the need remains nonetheless. As the authors of a review article on fetal alcohol syndrome in the Journal pointed out a quarter-century ago (S.K. Clarren and D.W. Smith. Letter to the editor. 1978;299:556), "a large number of congenital malformations and central-nervous-system dysfunctions will be prevented through maternal avoidance of heavy liquor consumption during pregnancy." The goal for the future should be the further refinement of evidence-based advice for pregnant women — a far cry from an anecdotal "handbook" of admonitions.
Lisa Chasan-Taber, Sc.D.
University of Massachusetts–Amherst
Amherst, MA 01003(By Elizabeth M. Armstrong)