Can routine screening for alcohol consumption in pregnancy be ethically and legally justified?

Abstract

In the UK, it has been proposed that alongside the current advice to abstain from alcohol completely in pregnancy, there should be increased screening of pregnant women for alcohol consumption in order to prevent instances of fetal alcohol spectrum disorder. The Scottish Intercollegiate Guidelines Network published guidelines in 2019 recommending that standardised screening questionnaires and associated use of biomarkers should be considered to identify alcohol exposure in pregnancy. This was followed in 2020 by the National Institute for Health and Care Excellence Draft Quality Standard, which recommended that pregnant women should have information on their alcohol consumption recorded throughout their pregnancy and this information transferred to the child’s health records. Most recently, Public Health England has stated that the alcohol intake of all women should be recorded throughout pregnancy, not just at the initial booking appointment and that tools such as blood biomarkers and meconium testing should be researched in order to determine true prevalence rates of alcohol in pregnancy. We argue that this proposed enhanced screening undermines women’s autonomy and their legal right to be sufficiently informed to consent to screening. We argue that there is no evidence that this kind of screening will result in a reduction of fetal harm and there is a danger that undermining the autonomy of women and the trust relationship between women and healthcare professionals may even increase harm to future children.

Using meconium to establish prenatal alcohol exposure in the UK: ethical, legal and social considerations

“…Such claims of a benefit for the future child through the prevention of harm are weighty. In line with the case made by Bennett and Bowden,10 we argue however they must be balanced against currently under discussed concerns about the effects of this definition of ‘routine’ screening for maternal and child health and maternal autonomy. We argue a meconium screen cannot be considered ‘typical’ when viewed within the scope of accepted screening tools in preventative medicine; we contend the routinisation of such screening is conflict with vital attention to autonomy and consent in the antenatal setting, and last, we argue for the priority of trust between midwives and women, which is jeopardised by this version of screening.…”

“…It cannot assist diagnosis of disease in either mother or child and cannot be seen as a public health intervention aimed at ‘avoiding harm’ as the ‘risky’ exposure has already taken place by the time the infant is born. Furthermore, as Bennett and Bowden note in their recent article on routine alcohol screening, the use of meconium has a clear disadvantage in relation to harm reduction in comparison with self-reporting, as the retrospective nature of the screen means it cannot be used to identify those pregnant women who may benefit from specialist services to reduce their consumption 10. Lastly, a positive screen of PAE from meconium screening is not a necessary requirement for a diagnosis, since this information can be provided through way less invasive means, namely self-reporting.…”

Knowing who to trust: women and public health

“…In this issue's Feature Article, Rebecca Bennett and Catherine Bowden explore recent proposals to enhance the screening of pregnant women in order to prevent instances of fetal alcohol spectrum disorder through more accurately determining the true prevalence of alcohol consumption during pregnancy. 3 Public Health England (PHE) has suggested research into tools such as blood biomarkers and meconium testing, 4 which could better identify those women who are consuming alcohol 'covertly' and so make FASD diagnoses more straightforward. As Bennett and Bowden rightly suggest, such a move is unlikely to realise the kind of public health or welfare gains which would justify this level of interference with the women's autonomy, and may even result in more harm through discouraging engagement with antenatal care.…”

“…In this issue’s Feature Article, Rebecca Bennett and Catherine Bowden explore recent proposals to enhance the screening of pregnant women in order to prevent instances of fetal alcohol spectrum disorder through more accurately determining the true prevalence of alcohol consumption during pregnancy 3. Public Health England (PHE) has suggested research into tools such as blood biomarkers and meconium testing,4 which could better identify those women who are consuming alcohol ‘covertly’ and so make FASD diagnoses more straightforward.…”

Kaleidoscope

“…Where does the needle lie in the complex area of mothers’ decisions affecting fetal health? Bennett and Bowden 7 ask about alcohol consumption during pregnancy to help prevent fetal alcohol spectrum disorder (FASD). The backdrop includes proposals in the UK that alongside current advice to avoid all alcohol during pregnancy (the ‘abstinence-only approach’ predicated upon there being no known safe level), there should be greater screening and potential use of blood tests and other biomarkers.…”