Ira J. Chasnoff, M.D.

Ira J. Chasnoff M.D.

Aristotle's Child

Alcohol, Pregnancy, and Racial and Social Class Bias

How racism and classism doom prevention efforts

Posted Dec 10, 2014

The irony of timing: just last month two articles appeared within weeks of each other.  The first was published in the on-line version of Cosmo magazine, detailing why a 30-something year old new mother had decided to have the occasional drink during pregnancy, ranging from an “apple-infused craft beer — ‘sippy cup juice for adults’”— to “a glass or two of wine or a couple of beers per week” and champagne at her baby shower.  

Coming quickly on the heels of that confessional came a new article published in Pediatrics, the journal of the American Academy of Pediatrics.  Conducted by Dr. Phillip May and his colleagues, the study demonstrated that up to 4.8% of children in a middle class American community met criteria for Fetal Alcohol Spectrum Disorders, the wide range of physical, behavioral, learning, and mental health problems associated with prenatal alcohol exposure. 

The Cosmo article makes for an easy target, and I hesitate to even bring attention to it.  However, what struck me most about the article, written by Michelle Ruiz, was the arrogance of privilege threaded throughout the article.  The author correctly references data from the Centers for Disease Control and Prevention (CDC) that show that white, college-educated, middle to upper class women are the most likely group to drink during pregnancy. From data like these, the author concluded that “… drinking while expecting is an ‘elite’ thing.”  The author then goes on with the following direct quotes scattered through the article:

“Why do more older, educated, employed women drink conservatively while pregnant, despite the Surgeon General's official warning against it?... (I)n my experience, these (we?) women are more likely to drink because they consider themselves, however arrogantly, smart enough to question the American medical standard.”

“Pregnant women who drink lightly in 2014 don't necessarily feel like rebels who are tempting fate. They simply believe that there is a secret code among them — that an occasional drink really is OK, but it's just too risky for many American doctors to share that with most of their patients.”

Echoing Emily Oster in her book Expecting Better: Why the Conventional Pregnancy Wisdom Is Wrong—and What You Really Need to Know, the author states that,

“…many doctors seemed to agree that a random glass of wine on a weekly basis probably isn't harmful, based on anecdotal experience and perhaps the foreign research too. But she also said she got the impression from doctors that they trust older, professional, more educated women with this inside information because doctors assume those women will actually keep pregnant drinking under wraps, whereas the general population might interpret the OK to have one glass of wine as a slippery slope to have more….This is the drumbeat of many pregnant drinkers (admittedly, myself included) — that they're privy to the inside info that doctors only tell their friends.”

Again referring to Oster’s book, the author reiterates that drinking during pregnancy is…“‘like a secret code.’ And the code is passed on among the statistically proven demo of thirty-something, educated, employed women.”

The author’s words espouse a vaccine that will protect the child born to a middle class, well-educated woman who knows doctors that tell her secrets so that she can comfortably drink during pregnancy.      

The same attitude can be found on the opposite side of the doctor-patient relationship.  In a study we published in 1990 (Chasnoff et al., The prevalence of illicit-drug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida. New England Journal of Medicine, volume 322: pages 1202-1206), we showed that white and African American women, whether they had private insurance or were on Medicaid, were using alcohol and illicit drugs at almost exactly the same rates.  However, physicians selected African American women for urine toxicology testing ten times more frequently than they ordered testing for white women.  This discrepancy was reinforced when one entered socioeconomic status into the equation.  In short, physicians selected pregnant women for drug testing based on two factors – race and social class. 

In our ongoing work with states and communities to develop universal strategies for identifying and promoting substance free pregnancies for women who are using alcohol, tobacco, and illicit drugs, we find that doctors are quite comfortable interviewing Medicaid-funded, minority – especially African American – women.  However, when pushed to extend these interviews to white, middle class women with private insurance, there is unremitting resistance.  The physicians make it clear – that’s not the population at risk.

Understand that these attitudes stand in stark contrast to the data that repeatedly have shown through a number of national studies by the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Services Administration that white, middle class women are the group of women most likely to drink alcohol during pregnancy. Our own research conducted for the State of California has shown that within a data set of pregnant women in California, the woman most likely to drink during pregnancy was white, middle class, and lived in San Luis Obispo in the heart of wine country. These epidemiologic data regarding higher socioeconomic class pregnant women’s drinking during pregnancy are bolstered further through the study by May and colleagues.

It appears that in the case of alcohol use in pregnancy, the old construct of “high risk” vs. “low risk” populations does not apply.  Our perceptions of risk, especially as identified through racial and socioeconomic factors, are false.  Is this racism?  Literally, racism is defined as a “belief in race.”  In this case, it is couched in the belief that race can tell you who an alcohol or drug user is.  This thinking easily extends into “classism,” as very ably demonstrated by Ms. Ruiz’s article in Cosmo.

This is why current prevention campaigns don’t work. These campaigns fail because they focus on informing people about the risk of alcohol use in pregnancy.  However, it is no longer an issue of ignorance; at a cognitive level, most people recognize the potential danger of alcohol use during pregnancy. Prevention efforts fail because the information applies to “them,” not “us.” And as long as attitudes of specialness within middle to upper class men and women hold, as long as physicians continue to deny that alcohol use in pregnancy is a universal problem affecting a significant portion of children across all walks of life in this country, prevention campaigns will continue to fall short. 

The failed logic in Ms. Ruiz’s article perpetuates the myth that there is a protected class. She uses as her examples of specialness her and her friends’ children, all of whom are quite young. By doing so, she disregards what can be called the “sleeper” effects of prenatal alcohol exposure; that is, the effects that begin to show up only as the child ages and faces greater developmental challenges.  This is what makes the article by Mays and colleagues so important. Think about it…up to almost 5% of children in a school system in a solid middle class community had been affected by their mothers’ use of alcohol during pregnancy. 

It’s true.  We don’t know how much alcohol is safe to drink during pregnancy, but numerous animal and human studies are working toward that definition.  Until these studies can define that level, we must continue to reinforce the message that no amount of alcohol is safe to drink during pregnancy.  But in a world where health care and social service policy is wrapped in an “us versus them” mentality, on a public as well as political level, it’s always “them” that are the problem, “them” that should be listening.  We should all be listening, for the problem is us; not women, not men, not the government. Us.

I’ll close with Ms. Ruiz’s own words: 

“I knew that drinking heavily during pregnancy would be a terrible thing and could cause Fetal Alcohol Syndrome, but I didn't — and still don't — think I was risking my baby's health by drinking small amounts on a sporadic basis. If I thought I were putting her at risk, I would never have done it.”

Please don’t.

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