Pregnancy Purity

Mom guilt begins at conception

I’ve recently been going down the rabbit hole of pregnancy recommendations. While Dr. GPT has been satisfactorily answering most of my questions, when it comes to inquiries about the risk levels of various behaviors, my artificial mentor often defaults to the “no amount of X has been proven safe” and “since there is no positive benefit of behavior X on chance of conception/miscarriage risk/baby’s long term outcomes… it’s best to entirely AVOID behavior X”. If I really press it it’ll sometimes give me numbers, but doing so makes it really uncomfortable, and any useful information is buried under a veritable mountain of caveats. Which is what led me to Emily Oster’s book “Expecting Better”.

The sections on caffeine and alcohol were frankly radicalizing. I came into this expecting that the official (and unofficial) recommendations would be unreasonably draconian. I expected that the risks of drinking coffee or enjoying an occasional alcoholic beverage while pregnant were likely tiny and would probably be within the tolerance range many women were comfortable with were they to know the actual numbers. What I didn’t expect was that some of these recommendations would be based on…. almost nothing at all. To be clear, herculean doses of caffeine are probably not a good idea (pregnant or not), and regular heavy drinking is associated with poor outcomes for the pregnancy and baby. But there seems to be pretty limited evidence that daily caffeine consumption of 200mg, or even somewhat above that, is harmful during pregnancy. And multiple studies fail to find adverse developmental outcomes from drinking even up to one standard drink PER DAY during pregnancy.

I won’t go too deep into the various studies, just read Emily’s book or check out her website if you’re looking for that. But to give you a sense of how some of these (apparently overstated) understandings of the related risks came to be seen as evidence backed:

1. Caffeine has been associated with miscarriage risk, and there are studies that show higher rates of miscarriage with > 200mg of consumption. But even at those levels, it’s not clear that caffeine has a meaningful impact. This is because there is a significant confounder in that nausea is associated with both a normally developing pregnancy and finding coffee off-putting. Quoting Emily, the study linked above “found no [statistically significant] effect of coffee among women who reduced their consumption, regardless of what their final consumption level was. Taken literally, this means that it doesn’t matter how much coffee you drink, as long as you reduce from your starting level. It’s hard to figure out why this might be, other than that women who are nauseated reduce their consumption.” Emily also references a study which found that decaffeinated coffee was as strongly linked to miscarriage risk as caffeinated coffee, which the authors note leads them to “suspect that this association was due to bias resulting from the relations among fetal viability, symptoms of pregnancy such as nausea, and consumption patterns during pregnancy.” Regardless, even the official ACOG recommendation allows up to 200mg per day, yet many mothers I know reduced much more significantly, or entirely stopped drinking coffee during pregnancy.

2. Heavy drinking is associated with various problems both for the baby’s later development and pregnancy outcomes, but the evidence for the effects of occasional light drinking are far less clear. This Danish study of over 1600 mother-child pairs found no evidence of an effect for light to moderate (up to one drink per day!) alcohol consumption on children’s executive function at age five, this companion study on the same cohort found no impact on IQ, and this Australian study of over 3700 mother-child pairs found no evidence of an effect for moderate drinking (again up to one drink per day) on cognitive ability, attention or learning outcomes at age 14. One study on which the claimed risks for even light drinking are apparently based involved a sample of 506 women, 42% of whom were USING COCAINE?? (Shockingly, the percentage of women using cocaine increased alongside their drinking, with 19% of abstainers using compared with 45% of “light” drinkers, and 70% of “moderate-heavy” drinkers). They found very modest increases in parent-reported aggression and other behavioral issues even for the low (up to 0.5 drinks per day, median of 1 per week) group. Reading this, I couldn’t help but wonder…. could it have been the cocaine that caused these negative outcomes and not the half glass of wine soon-to-be mommy had with dinner?? While the authors do attempt to control for cocaine use and still find a negative impact of light drinking, they only control for cocaine as a binary variable, losing any information related to the amount of cocaine being used by these moms. Altogether, the evidence that light drinking is harmful to your baby or pregnancy is at best very weak. There are countless things which are completely fine in moderation and bad in excess, and the evidence seems to suggest that light to moderate drinking during pregnancy may be one of them. The line that “no amount of alcohol has been proven safe” is a non-starter, since essentially nothing can be “proven safe” in the absolute sense of proving zero risk. The scientific method can only conclude that there is no evidence of harm, it cannot prove the risk is literally zero.

The overall pattern that emerges is one where the rules, recommendations and norms around these sorts of consumption choices are meaningfully stricter than you’d expect based on the evidence alone. In my social circle about 80% of moms I know reduced caffeine well beyond the ACOG recommended limit of 200mg per day. All of the moms I know reduced alcohol to near-0, with some having a glass of wine at a few special events later into pregnancy. Some of this was related to nausea with neither caffeine nor alcohol being desirable for some, especially early in pregnancy. But in basically all cases the desire to reduce risks to the pregnancy and baby, and the perception that these changes would help accomplish that, played a role as well.

When I say the norms are stricter than “you’d expect”, what I mean is that these changes to consumption patterns represent a significant (though generally not devastating) cost to the mothers making them, without much evidence that they actually reduce risks to the pregnancy or the baby’s development. It often seems to come back to “it hasn’t been proven to be safe, and there’s no positive impact for the baby, so… why risk it?”. Well… maybe because it makes things easier/more pleasant for the pregnant woman? Because it is difficult and stressful to follow all these rules (including long lists of unallowed foods) for 9 months? Because… the pregnant woman’s subjective experience, comfort and freedom should be given at least some weight when making these decisions?

Of course I acknowledge that mothers (who want the baby) should modify their behavior as needed to promote a healthy child and a safe pregnancy, and of course they very much want to! During this period their focus is largely on their growing child, and they are more than willing to make behavioral sacrifices in addition to the burden of actually carrying the baby. But a willingness to sacrifice doesn’t imply that making these sacrifices is a good in and of itself. When the health of the baby and the subjective experience of the mother are in real conflict, it’s certainly reasonable to put more weight on what’s best for the baby. But when I look at the (lack of) evidence supporting some of the common restrictions recommended to pregnant women, my impression is that we are implicitly giving 0 weight to the mother’s experience and infinite weight to the future child. A pregnant woman is an individual with her own needs and wants, AND she is also a vessel for new life. We need to absolutely recognize the vessel piece, but we don’t need to entirely devalue her experience in the way that our social norms, in light of the available evidence, imply.

I’m not claiming this is all externally imposed. The pregnant women are themselves active participants. My speculation is that soon-to-be mothers are subconsciously acting out a belief that the more they sacrifice, the more they’re proving their love for their future child. I mean… compared with a beautiful baby is it really that big of a deal to get off caffeine (you freaking fiend)? But there is obviously a social element. Whatever the norm is in your social circle becomes the bar you measure yourself against. And if you’re not as strict as your friends were, or you don’t max out on all the restrictions, I imagine it’s easy to feel like a “bad mom” even before you’ve become one.

While some of this is self-imposed, friends of mine who consumed caffeine or small amounts of alcohol during pregnancy reported receiving shaming comments from strangers, friends and family. I’m not a parent yet, but parenting sure seems like a lot of work, especially for mothers. And with all the talk of how to increase the birthrate and make parenting more enjoyable, maybe one place to start is less restrictive, more evidence-backed recommendations regarding behavior during pregnancy. “Mom guilt” is apparently an epidemic. Let’s not encourage it before the baby has even arrived.