By Professor Moira Plant
A number of contributors will explore Fetal Alcohol Spectrum Disorder (FASD) as part of FASD Awareness Month. FASD is usually viewed through the lens of risk to the child, however I decided to look at this from a different perspective: that of the woman. This blog considers how public health advice can protect children without overlooking women’s health, rights, and circumstances. It also explores the tensions around choice, stigma, and the realities that can limit a woman’s agency.
Women’s rights, pregnancy, and public health
The question most health professionals don’t even ask is: “Is focussing on women abstaining from alcohol during pregnancy a valid request or is it a way of restricting women’s rights?”. The knee jerk reaction among many health professionals is OF COURSE it is a valid request: there are two entities involved – the woman and her foetus. Yet women have fought for decades to be seen as more than carriers of the next generation. Among other groups, however, the focus may be more on the rights of the woman as a person who has rights and can make decisions about her body, regardless of whether there is another being within that body.
A major researcher in this field is Professor Sarah Roberts who, along with colleagues has monitored changes in strategies in different parts of the US and the impact this has had on birth outcome. One article by this group published in 2017 explored the issue of the possible conflict between the pregnant woman and her foetus. Uncomfortable as it may be, even giving clear advice of the risks of drinking in pregnancy, there are many women may choose to continue drinking through their pregnancy. Even now, far more women than the health professionals would like will continue to drink alcohol when they are pregnant.
So, what is to be done? In some countries, such as the US, policy decisions have been made in this area. These policies can be divided into two types
- Supportive
- Punitive
Supportive policies include exactly what the word says: providing continuing support throughout the pregnancy. Brief interventions are now available in many ante-natal clinics. For women whose drinking is defined as “problematic” there may be priority substance use treatment pathways. An important issue, given the time pressure of pregnancy. Other supportive policies include warning signs, usually found at points of sale.
For many people in the FASD field, if they are honest with themselves, they are frustrated with any woman who continues to drink after they have been given the information on the risks to the unborn child of drinking in pregnancy. They believe that this is a situation where an external control is acceptable, indeed necessary. Where does that take us? Well, it can take us down the path of punitive policy measures. This type of policy includes bringing in child protective services, criminal prosecution – there are states in America that have imprisoned women for drinking when they are pregnant.
A US study comparing state policies targeting alcohol use in pregnancy to overall drinking in pregnant women over a period of thirty years showed that mandatory warning signs were associated with “lower odds of binge drinking” (Roberts et al 2019:213). An important point, given our pattern of drinking is a Northern European pattern of binge drinking. This was an interesting study, which reported a rather mixed group of results: “—Priority treatment for Pregnant Women and Women with Children was associated with higher odds of drinking. Relative to no policies, punitive policy environments were also associated with more drinking but not with binge or heavy drinking. Of individual punitive policies, only child abuse/neglect was associated with lower odds of binge and heavy drinking” (Roberts et al 2019:213 – 214).
One example of a policy which covers the issue of most effective reduction in alcohol related harm is price. Scotland has led the way in introducing a minimum price for alcohol. Not only for pregnant women, but for everyone. A recent US study (Subbaraman M.S. et al 2026) explored the association between alcohol sales taxes and reduction on preterm births and low birth weight – both may be related to prenatal alcohol exposure. This study concluded “State-level beverage-specific sales tax are associated with fewer adverse birth outcomes. This study provides additional evidence that increased alcohol taxes may be relevant for reducing adverse effects related to pregnant people’s alcohol consumption” (2026:1).
It is important to remember that association is not cause but given the positive results of reduction in alcohol consumption with minimum unit pricing in Scotland this issue is worth considering in the toolkit of reduction in prenatal alcohol consumption.
In relation to collecting comparable data, it is becoming increasingly clear that one international FASD diagnostic criteria is needed. Scotland has the SIGN Guidelines, another important step forward. A recent article (Reid et al 2022) captured information from a number of countries on the willingness to support a consistent international FASD approach (90.9%) of the 147 clinics involved. The major barrier to this was lack of collaboration.
Stigma, shame, and guilt
Other thorny issues which are frequently brought up in relation to prenatal alcohol exposure and poorer birth outcome are those of stigma, shame and guilt. Guilt and shame are both exacerbated by stigma and these can last the woman’s lifetime. As noted by Zabotka et al (2017), guilt persisted “no matter what the age of the child or the length of time since diagnosis” (2017.262). A study among aboriginal/indigenous women in Canada (Salmon et al 2007) reported that the stigma of FASD is now so strong that increasing number of women were more likely to admit using any drugs other than alcohol. As noted by Choate and Badry (2019), the issue of stigma is not linked only to individuals with FASD but also their support systems.
Focussing back on health professionals. A study by Mukherjee (2015) reported that in a group of UK professionals (n=505), 60% of respondents identified FASD as a stigmatised condition. Interestingly, 72% of paediatricians acknowledged they viewed this diagnosis as stigmatising. This may be one of the reasons for the ambivalence some midwives experience about asking women about their drinking at their first ante-natal appointment. The debate is simple: do you wait until you, as the midwife, have a sense of developing a working relationship with the women – acting as a team to provide the best possible care and good outcome for both? OR do you ask at the first appointment for information about the woman’s alcohol consumption? An obvious factor is one of timing. A first clinic appointment may be as late as 12 weeks, almost past the first trimester organ development stage. This makes it sound simple: OF COURSE the sooner questions about alcohol consumption can be asked, the better for the foetus. But what about the mother? Will being asked these questions mean she stops attending regular ante-natal clinic appointments? Midwives are still debating this.
To me this area of stigma is particularly powerful in FASD. Women are doubly stigmatised, women and alcohol and women and the children they bear. The hand that rocks the cradle must never be seen as shaky.
Feelings of guilt and shame can trigger the powerful defence mechanism of denial. Another feeling closely related to shame is fear. Imagine a young woman who realises she is pregnant but still wants to go out with her friends on a Saturday night. She heard she’s not supposed to drink when she is pregnant but if she refuses a drink one of the first questions her friends will ask is “Are you pregnant?”. Imagine the fear she is experiencing, the isolation, the terrible secret she is unable to tell her friends, her family, and even herself. This young woman and thousands like her need support from health professionals not judgement.
Having worked in this field peripherally for many years, one thing still stands out: no matter how harshly health professionals and others judge a woman who gives birth to a child with harm from prenatal alcohol exposure, NO-ONE judges her more harshly than she judges herself.
Domestic violence and agency
This brings me to my last point, that of agency. Agency is defined as “a person’s capacity to initiate, direct, and control their own actions and decisions to influence their environment and outcomes” (Wikipedia).
This aspect is often missed in the drinking in pregnancy debate. In Scotland specifically, and in the UK in general, the proportion of unwanted pregnancy is high. One example of this may be the aforementioned young woman out drinking with her friends. An even more pressing one is that of a woman caught in a situation involving domestic violence. Take another example a woman buying alcohol for her abusive partner reading a warning label discussed above. The people who produce these are extremely skilled at bringing out the positives – a healthy baby – a healthy mother, and for most people that is the way they are read, but what about the women in abusive relationships where the male partner wants her to drink with him? How much agency does she have?
In Scotland at this point, we do not know how many instances of domestic violence are perpetrated against pregnant women. What we do know is that in 2025, there were 66,515 incidents of domestic abuse recorded by Police Scotland. All evidence would point to this being an underestimate. Up to now, it has not been possible to pull out data on pregnant women, so we do not know how many of these instances involved pregnant women. However, we do know that the two most dangerous times for a woman in an abusive relationship are if she threatens to leave, or does leave, a violent partner, and when she is pregnant.
Scotland may be stepping up action to address violence against women and girls and a recent consultation proposed that violence involving women who are pregnant should legally carry an added aspect of “statutory aggravation – offences committed against pregnant women”. This will enable the justice system to take the issue of pregnancy into account at the time of sentencing. It will also mean we will be able to collect statistics in this area.
Although this may take a year or two to come into force, it is an acknowledgement that all pregnant women do not have the agency many people assume they have. In short, they can feel stuck between a rock (a violent partner) and a hard place (a healthcare system that states drinking in pregnancy may harm your baby).
Future planning: data and funding
Scotland is a small country with a continuing ambivalent relationship with alcohol. However, being a small country means it is possible for us to develop a plan to enable retrospective and prospective data collection of alcohol consumption in pregnancy and birth outcome.
One relatively inexpensive way to give an overview is already in place: through the retrospective measurement of the effectiveness of factors such as increased price. This could be also used effectively to monitor other aspects matching the introduction other measures to the country’s improvements in a variety of health issues. In this case, drinking in pregnancy and foetal outcome.
As a researcher people will not be surprised when I say we need money specifically for this area. It cannot be done along with other work. Ideally ring-fenced money is needed for a period of at least ten years to enable us to monitor innovative ideas and their effectiveness.
Reference List
Choate P and Badry D. (2019) “Stigma as a Dominant Discourse in Fetal Alcohol Spectrum Disorder” Advances in Dual Diagnosis 12 (1/ 2) 36-52.
Mukherjee R. (2015) “Knowledge and Opinions of Professional Groups Concerning FASD in the UK” Adoption and Fostering. 39 (3) 212-224.
Reid N. et al (2022) “International Survey of Specialist Fetal Alcohol Spectrum Disorder Clinics: Comparison of Diagnostic Approach and Considerations Regarding the Potential for Unification” International Journal of Environmental Research and Public Health 19 15663
Roberts S er al (2017) “Forty Years of State Alcohol and Pregnancy Policies in the USA: Best Practices for Public Health or Efforts to Restrict Women’s Reproductive Rights?” Alcohol and Alcoholism 52 (6) 715-721.
Roberts S.C.M. et al (2019) “State Policies Targeting Alcohol Use During Pregnancy and Alcohol Use among Pregnant Women 1985-2016: Evidence from the Behavioral Risk Factor Surveillance System” Womens Health Issues 29 (3) 213-221.
Subbaraman M.S. et al (2026) “Alcohol State Taxes are Associated with Reduced Preterm Birth and Low Birthweight in the United States” Journal of Studies on Alcohol and Drugs Published online February 16th
Zabotka J., Bradley C. and Escueta M.T. (2017) “ How Could I Have Done This?” Thoughts of Mothers of Children with Fetal Alcohol Syndrome” Journal of Social Work Practice in the Addictions 17(3) 258-274.