Last year, the CDC ignited a firestorm of criticism by stating that women should “stop drinking alcohol if they are trying to get pregnant or could get pregnant”, and–because an estimated 50% of pregnancies in the U.S. are unplanned–any woman who drinks alcohol should use birth control.
“Its [the CDC’s] underlying message was unmistakable: Women should consider themselves first a vessel for human life and make decisions about their health and behavior based on that possibility,” Rebecca Ruiz wrote at Mashable, in a typical reaction.
The (completely understandable) outrage at the CDC’s tone-deaf and condescending messaging has, unfortunately, drowned out information on the key question for many pregnant women: Is any amount of alcohol during pregnancy okay? And are there times when it should be absolutely avoided?
We all know that heavy drinking and binge drinking are harmful during pregnancy. Fetal alcohol syndrome, caused by heavy drinking during pregnancy, affects an estimated 2 to 7 children out of 1000. Another 2 to 7% of U.S. children are thought to suffer milder forms of cognitive impairment due to alcohol exposure in the womb.
But what about light drinking, a champagne toast or an occasional glass of wine at dinner? Women–pregnant, pre-pregnant, and otherwise–receive conflicting advice about the safety of light drinking.
Economist Emily Oster, in her bestselling pregnancy advice book Expecting Better, says pregnant women can be comfortable with “1 to 2 drinks a week in the first trimester” and one drink daily afterward, a stance she continues to stand behind.
Many doctors also greenlight the occasional drink, as Ruth Graham of Slate notes: “Many doctors seem perfectly comfortable with moderate alcohol consumption in the late stages of pregnancy. When I told my doctor that I was enjoying a glass of wine per week in my third trimester, she didn’t bat an eye.”
The CDC, on the other hand, maintains that no amount of drinking is safe.
“Any drinking is going to put your child at risk,” according to Clark Denny, a CDC epidemiologist. “You should not drink if you are pregnant, are considering getting pregnant or even if you could possibly get pregnant.”
Other countries, like the U.K. and France, that once gave less stringent advice–pregnant women should not exceed 1-2 drinks per week–now state no amount of drinking is safe, and that women who are pregnant or trying to conceive should abstain entirely.
At the heart of this debate is the research itself. So, what do we actually know about light drinking during pregnancy?
Let’s start with alcohol and the risk of miscarriage.
- Light drinking, the equivalent of 1-2 drinks per week, during the first trimester, boosts the odds of a first trimester miscarriage by about 30%, and the odds of a early second trimester miscarriage (between 13-16 weeks) by about 70%, according to a large study of over 90,000 pregnancies in Denmark. The risk rose with greater intakes. Drinking 4 or more drinks per week during the first trimester more than doubled the odds of a miscarriage. A U.S. based study found that women who drink 2 times per week in their first trimesters had a 25% chance of miscarriage, compared to a 14% chance for those who abstained. Other studies also find a higher risk of miscarriage for light drinkers (see here and here).
Does this mean that light drinking early in pregnancy causes miscarriage? Unfortunately, we cannot say for sure. Experimental studies in humans are impossible, so there are a lot of unknowns.
For one, some women may understate how much they actually drank during pregnancy, so the apparent rise in miscarriage could actually stem from moderate to heavy, rather than light, drinking.
Women who drink heavily during pregnancy often also smoke or have partners who smoke, and are more likely use drugs, receive worse prenatal care, live in poverty and experience extreme chronic stress–all of which can raise the risk of miscarriage and cognitive problems in their children, and any and all of these factors could exacerbate the toxic effects of alcohol on the fetus.
Poor nutrition and smoking seem to worsen the effects of alcohol. This makes sense, as alcohol lowers how much nourishment reaches the fetus.
Women who drink alcohol during their first trimester may have less nausea. (I for one could not get near alcohol in my first trimester, as much as I might, after a long day of nausea and chasing after a toddler, desire a drink.) Although about 25% of women do not experience nausea during pregnancy, an absence of nausea is linked with an increased risk of miscarriage, probably because poorly developing pregnancies produce fewer symptoms.
And finally, the problem may not arise from drinking during early pregnancy but from drinking before pregnancy.
2. Drinking alcohol may lower the chances of pregnancy, and increase the chances of miscarriage, by causing chromosomal abnormalities in the egg before ovulation. Alcohol has been shown to impair meiosis, the critical two-step cell division in maturing egg follicles, leading to chromosomally abnormal eggs. Chromosomal abnormalities account for over half of first trimester miscarriages. Worse, because eggs take several months to fully mature, even drinking in the months before conception could be harmful.
How much alcohol do you have to drink to harm your eggs? Again, we don’t have a good answer. The degree of harm likely depends on a lot of other things, like your age, your overall fecundity, your alcohol tolerance, how much alcohol you drink, and when you drink relative to critical phases in the egg’s development.
Clearly, even formerly heavy drinkers go on to have chromosomally normal and perfectly healthy pregnancies, so the effect is not absolute. The increase in chromosomal abnormalities is probably most problematic for couples already suffering from fertility issues. Among couples undergoing IVF, for instance, drinking appears to lower their chances of pregnancy.
Because the human data are limited, we have to turn to animal models. In one study using monkeys, the equivalent of binge drinking (4-5 drinks at a sitting) twice a week lowered the number of chromosomally normal eggs and increased the chances of miscarriage.
3. Alcohol does not reach the developing embryo until the 3rd week after fertilization, or pregnancy week 4, right after most pregnancy tests turn positive. In other words, even if you got pregnant on your honeymoon while more than a little tipsy and drank cocktails on the beach for the rest of the week, you have nothing to worry about. That alcohol did not reach your embryo.
What about harm to the fetus’s developing brain? Here’s the problem: No one knows at what threshold drinking alcohol becomes harmful, and that threshold may vary from person to person, just like alcohol tolerance and metabolism varies from person to person.
Heavy drinking and frequent binge drinking are clearly bad, but what about that occasional glass of wine or cocktail?
Emily Oster finds the not one drop rule propounded by the CDC and others absurd, and it’s easy to see where she is coming from. Lots of chemicals known to be harmful in large quantities are completely safe in small amounts. As she puts it,
“If you have too many bananas (and I mean a LOT of bananas), the excess of potassium can be a real problem, but no doctor is going around saying “No amount of bananas have been proven safe!” He’d be laughed out of a medical conference.”
But this argument, a version of the Paracelsus principle–the dose makes the poison–depends on the poison in question. Some toxins, like lead, are unsafe at any amount.
We don’t have great information about the actual threshold at which alcohol causes harm, or when harm is most likely to occur. But let’s sift through what we do know.
4. By the third week after conception (the 5th week of pregnancy), alcohol and its byproducts cross the placenta. Based on animal research, the fetus is believed to experience the same blood alcohol level as its mother.
5. Alcohol is a known neurotoxin. Although how alcohol causes damage is not entirely clear, neuronal loss with heavy or binge drinking is evident in animals and in humans. Harmful effects may be especially pronounced in the developing brain, particularly during the first trimester, when many of the changes in facial morphology in FAS appear to originate. Damage to slow growing brain structures, like the cerebellum, likely occurs throughout pregnancy.
6. Large epidemiological studies find no evidence of cognitive impairment with light drinking (1-2 drinks per week) in the second and third trimesters and less than a drink a week, on average, in the first trimester. This research is the basis of Emily Oster’s claim that a drink a day in the second and third trimesters is okay.
One of the largest of these studies is the U.K. Millennium cohort, which has followed a nationally representative sample of 11,000 children born betwen 2000-2002. At age 3, age 5, and age 7, both boys and girls whose mothers drank about 1-2 drinks per week actually had better overall cognitive performance and fewer behavioral and attention problems than children whose mothers abstained from drinking during pregnancy. Heavier drinking, on the other hand, was associated with worse cognitive performance and more behavioral problems.
(The higher test scores among children of light drinkers was almost surely NOT because alcohol benefited their development, but because women who drank lightly were on average more educated and of a higher socioeconomic status than women who abstained. This confounding of light drinking with education and socioeconomic status is actually a huge problem for interpreting this study’s results. Parental education, income, and social class all predict better cognitive performance and fewer behavior problems. So, who is to say that these children would not have been more advantaged had their mothers abstained throughout pregnancy?)
Other studies have found no effect on test scores or mental health at age 11 among children of mothers who drank less than 1 glass per week during their first trimester; no increase in mental health or behavior problems among children of light drinkers at age 2, 5, and 8 (but worse mental health seen among moderate, binge, and heavy drinkers); and no impairment in cognition, learning, or attention among 14 year olds whose mothers drank an average of less than a glass a day early or late in pregnancy; and no reduction in IQ, attention, or executive function at age 5 in women who drank up to an average of 5 drinks per week.
In short, light drinking during pregnancy, less than a drink a day on average, and no more than 1 drink at a sitting, has not been shown to cause detectable harm.
Because light drinking is more common among highly educated, high income women, the advantages of which could mask any subtle impairments caused by small doses of alcohol, we need to take these findings with a grain of salt.
7. Individuals in how quickly they metabolize alcohol and its byproducts. These differences probably influence the threshold at which alcohol causes harm to a fetus. Even among those who drink heavily during pregnancy, only about 5% will give birth to a baby with Fetal Alcohol Syndrome.
A recent study looking at IQ at age 8 found similar results for moderate drinkers. Among slow alcohol metabolizers, moderate drinking (1-6 drinks/week) was linked with lower IQ. No link was found for fast metabolizers, or among poor metabolizers who abstained from alcohol.
The Bottom Line
Drinking more than 2 drinks a week in the first trimester appears to substantially increase the risk of miscarriage. That said, we do not know whether alcohol causes miscarriage. A lack of nausea, or other problems that often go hand in hand with drinking, like smoking, may contribute to this effect.
Alcohol causing miscarriage, however, is biologically plausible. Alcohol can cause chromosomal abnormalities in the egg prior to conception. This does not happen all the time. We all know that alcohol use before conception can lead to perfectly healthy pregnancies. Still, couples who are struggling to conceive may boost their chances by abstaining from alcohol.
What about children’s cognitive abilities and emotional and mental health? Here, very light drinking, less than a drink per week on average, has not been not been shown to be harmful. And many studies find no harmful effects of 1-2 drinks per week.
However, women vary considerably in their ability to metabolize alcohol, based on their body size, liver size, and genetics. Other factors, like whether you drink with food and how quickly you drink (no tequila shots, please!), also affect the amount of alcohol reaching the fetus. These facts make setting a “safe” threshold is impossible.
Given this variability, here’s my personal take: It seems wise to largely avoid alcohol during pregnancy, especially during the first trimester. An occasional glass of wine drunk slowly with dinner is probably fine, but I personally don’t see the upside to pushing the limits.
At the same time, women who drink a glass of wine here and there have no cause for alarm. The CDC’s draconian, not-one-drop stance is probably based on a slippery slope argument. They worry that if they say an occasional glass of wine or beer is fine, women will read their recommendation as license to overindulge.
On the other hand, Emily Oster’s advice to drink “up to 1 drink a day in the second and third trimesters, and 1 to 2 drinks a week in the first trimester” feels too risky for my blood. Most studies define light drinking as 1-2 drinks per week, much lower than Oster’s recommended maximum for the second and third trimesters.
At the end of the day, every woman is going to weigh the risks and benefits of light drinking a little differently. A reasonable woman could see the available evidence and feel comfortable with 1 to 2 drinks a week; another reasonable woman could see the available evidence and decide to abstain entirely.
Curious about drinking after pregnancy? Check out my post on drinking while breastfeeding.
Yes real numbers and no fear tactics! Stressed the importance of avoiding alcohol which being realistic. This is why we love you.
Thank you! That was my hope for this post.
Wonderful post: I appreciate the careful analysis and provision of citations.
One thing did puzzle me. You say:
4. By the third week post-conception, pregnancy week 4, alcohol and its byproducts cross the placenta.
This is not an area where I have expertise but everything I’ve read suggests that “by the third week post-conception” is right (placenta begins developing on day 14, I’ve heard differing claims in when it’s developed enough for alcohol to pass, sometimes “as early as day 14” other times around day 17. But they are all within that window). But I’m confused by how 14-17 could possibly be “pregnancy week 4”. I assume by pregnancy week we mean “as doctors and pregnancy books count”. Which is from the first day of the last period. So 14 days before ovulation.
That means that you should always add 2 weeks to the “post conception” week to get the “pregnancy week”. No? So it’s week 5. Or am I missing something? If anything it should be a little more than 2 weeks (since conception can happen for a couple days after ovulation but never before).
This seems like a petty issue but for most women trying to get pregnant it’s the difference btw a policy of “relax and just stop drinking when you miss your period” vs. ” stop drinking every month at least a week before then wait”.
The CDC website systematically uses pregnancy dates for describing when women know they are pregnant leaving one with the misleading impression that many women are exposing their fetuses for 1-2 months.
Thanks for noticing this! Yes, it is after week 4, counting from the first day of your last menstrual period, or the 5th week of pregnancy. Updating now…
I’m so glad to see this clear and unbiased summary! I wasn’t quite sure what to make of the CDC’s recommendations, and this is really helpful. Thank you!
You’re welcome! Thanks for reading.
Thanks for this review! Women deserve to have these sorts of conversations with their providers instead of fear/guilt-based mandates. I also find the history of FAS to be so interesting. I recommend this article from Social Science Medicine if you can get your hands on it, “Diagnosing Moral Disorder: The Discovery and Evolution of FAS,” by Elizabeth M Armstrong (1998).
Thanks! I’ll check it out.
I’ve just discovered your website, & loved the first article I read. I also appreciate the fact that you’re bringing the science & facts & giving all the information. Being someone who is young, an independent thinker, possessing far too few worrywart cells & being open to adapting & embracing ‘new’ research, rather than what the 27 lovely aunts/grandmas/parents I have tell me, after reading this article I would start having a guilt-free drink a week as I’ve just hit second trimester for baby #2, and have never abused alcohol in my life, so it’s not exactly going to be a problem stopping at 1 for me.
Except one MAJOR factor. I grew up with a sibling who had such “mild” FAS symptoms that it didn’t even get diagnosed (the birth mother wouldn’t admit to drinking) My entire memorable childhood has this sibling living with us in it, so for all intents and purposes she may as well be my blood relative. I can’t even begin to put into words the hell & hardship we went through, from so many angles, at so many different times, in every area of her life. I suspect (but don’t know) that it’s harder to parent & live with someone with subtle brain damage than anything more severe or obvious. Because of the stability, learning & love in our home if you were to meet her even today, you would have to spend quite a while talking to her before you might even realise something serious was not quite right.
I don’t know how I can stress that I would never risk having anything even one tenth as bad happen to a child I was entrusted to look after.
Maybe the incontinence that stretched well into teenage years?
Or the complete lack of cause-consequence connections in the brain?
The fact no type of positive or negative reinforcement ever. worked. Believe me, we tried it all. I have such wonderful parents who somehow never gave up.
Social incompetency (i.e. no stranger danger whatsoever) that went from mildly inappropriate and awkward as a child but has since led to sexual abuse & what I can only assume contributed to a dysfunctional teen pregnancy.
I had no idea the percentage of FAS was so low, but I just wanted to share how life-shattering that percentage is. I know I’ve barely done it justice, but please hear that I wouldn’t wish it upon anyone.
The fact that we all process alcohol differently & cannot know what impact any amount is going to have on us & our baby, means that a recommendation to avoid it is entirely reasonable.
I just felt your overall tone was a little dismissive of such a horrific syndrome, with far-reaching impact & although you were clear we cannot know some effects of alcohol for sure, I was certainly close to being convince “she’ll be right” when in fact I truly believe that it’s better to be safe than sorry on this particular subject.
Maybe the CDC could simply give a little more info behind their stance, a simple percentage of risk rather than “you’re putting your baby at risk by drinking anything” would make a lot of difference I suppose.
And, off I go to read more articles on here… 🙂
Thanks for all your thoughtful comments today, Nicole. I cannot imagine how hard it must be to see firsthand someone whom prenatal alcohol exposure has permanently damaged.
I certainly did not mean to dismiss the very real risks of prenatal alcohol exposure. Rather, I wanted to point out what we know from the research, and what we do not. I think for many women, scary blanket statements are not convincing–and they want to review the information themselves. I am one of them, obv. 🙂
For what it’s worth, I am also in the better safe than sorry camp on most things parenting-related, but I can also see other side, and I try very hard to not recommend any specific behaviors, and to be clear about what is my opinion versus fact.
Happily stumbled across this website while in search of some reason amongst all the pregnancy fluff. I really appreciate your measured approach to different issues. I’m a medical doctor (no, not an obstetrician!) and have recently learnt I am pregnant (~4 weeks post conception) and have been wracked by guilt and panic when I recall the alcohol I’ve drunk in the last few weeks (attended a wedding and a 30th birthday unaware I was pregnant at +3 weeks post conception). Reading the absolute and uncompromising advice online about alcohol and pregnancy, I’ve never felt more ashamed – and I even discussed termination of a much wanted pregnancy with my husband. I understand I’ve likely put this pregnancy and fetus at risk – but delivery of this message can be so destructive.
I’m so glad this post was helpful to you. Obviously, I cannot tell you what to do with this pregnancy and I understand completely why this situation would be stressful. Still I feel compelled to tell you that I know many people who were in similar situations who have given birth to healthy, happy, and very bright children. The not-one-droppers cause a lot of alarm but do not have data to back themselves up.
Hi Amy- I am 37 and had 2 miscarriages. One due to a known chromosomal abnormality (triploidy) and a MMC at 10 weeks that likely was also due to a chromosomal abnormality. My husband and I made the mistake of conceiving our first after our honeymoon in Europe which involved daily wine drinking for 2 weeks. I blame my triploidy pregnancy on delayed ovulation, which also could have been caused by stress. We are getting ready to try again, but I am worried because we visited wineries and breweries last week while on vacation and drank 4 days out of 7, I worry that I should stop drinking and wait another 1-2 months before TTC again to better my chances of getting a chromosomally normal egg. My FSH and AMH are both very good for my age, so egg quality issues are going to be environmental and not due to hormonal influences. Is there any research showing that risks of miscarriage decrease if a woman refrains from drinking for 3 months?
Amy, it is irresponsible to make a blanket statement giving permission for pregnant women to consume 1 or 2 alcoholic drinks per week. Do you know what a standard drink size is? Do you know that every woman is actually consuming a 4 oz. glass of wine, and not filling a goblet? Do you know that some women do not stop at 1 or 2 glasses? Do you know that the stigma associated with alcohol consumption during pregnancy often prevents women from truthful disclosure? Do you know that a woman could be 3 or 4 months pregnant and not know it?
Thank you, Nicole Parker, for sharing your honest experience about the effects of FAS/FAE. I work with those who will have a lifetime struggle due to a mother’s use of alcohol during pregnancy. If you don’t want to be pregnant, use contraception. If you do, then make sure you are giving your child the best possible chance by eliminating alcohol consumption before you conceive. If you are struggling with a substance use disorder, please reach out and allow someone to support you in your recovery.
FAS is 100% preventable and yet, is the leading cause of intellectual disabilities in the United States. That is the truth.
No safe amount. No safe type. No safe time.
I think if you read my post carefully, you will see I am not making any such blanket statements. I do not give any recommendations whatsoever, just a close reading of the available research and my personal take on the matter.
Enjoyed the article. I am curious about what you wrote regarding not feeling neausea and the risk of miscarriage. Most everything I read does not suggest that a lack of pregnancy symptoms necessarily means or even increases risk miscarriage. Could you point me to your source for this information?
Thanks! I have an article on nausea and miscarriage risk that cites several large-ish studies. Look under the pregnancy tab.
Stumbled across your blog by reading the miscarage stats article, really enjoyed the amount of quality information and data here. Would be also very useful to know if there’s any study on men’s drinking before and around the time of conception and its effects 🙂
Am currently 8 weeks pregnant.
I ate chocolate lindt mini pralines .
But only yesterday I found that few mini pralines namely (pistachio marzipan,Orange marzipan,truffle Marc de champagne) contains alcohol. I had no idea that it had alcohol before having that.
Am scared to the core now. According to the calculation I had around 1.5 ml of alcohol chocolate.
Am not sure what kind of alcohol was used to make those chocolates.
Can anyone please help me with this?
It sounds like they had so little alcohol that you felt nothing. I would not worry about it! There’s no evidence that trace alcohol such as found in a truffle will hand your baby.
Thank you Amy for the information you have given here.
I’m currently 18weeks and been suffering severe anxiety attacks over the last week due to thinking about the alcohol I have consumed during my pregnancy and the risk that I have harmed my baby.
During the first week after conception I was on holiday with friends, drinking moderately every day and with one day of heavy drinking. I then drank moderately over the following 2 weeks prior to taking a positive test. However, i’d been advised by my Mum who’s a nurse that I can continue having up to 1 glass of wine every week or two after, so I did – having consumed about 10 units over the last 13 weeks.
However, a few sleepless nights browsing the Internet began these anxiety attacks, wrecked with guilt. I know that stress and anxiety are also detrimental for the baby but it’s so hard to stop! However this article has helped calm me down. Whilst I won’t be drinking a drop more as the anxiety isn’t worth it, i’m hoping this means that seeing as all tests and scans show my baby is growing healthily at the moment, it should be fine.
My doctors are annoyed with me for drinking a half ounce of wine each Sunday (I’ve abstained from nausea lately, but intend to go back to it when I can tolerate it). This seems excessive–one EIGHTH of one unit of alcohol is going to cause problems?
Thank you for this! I will be 19 weeks pregnant when I go on a holiday with my husband and was hoping to have a glass of champagne when we go out to dinner one night! Thanks for the honest and measured advice. 🙂