Alcohol is the most dangerous substance to use in pregnancy. It is the only substance we discuss that is associated with permanent and severe harm to the infant. If you have several goals for several substances, please consider quitting drinking first.

In many cultures, alcohol use - especially heavy use and binge drinking - is considered more improper for women than for men. In general, women use alcohol at rates far below their male counterparts, but they have been catching up (3). 

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According to the Centers for Disease Control (CDC), 75% of people who are trying to get pregnant do not stop drinking alcohol, and the national prevalence of Fetal Alcohol Spectrum Disorder (FASD) is estimated to be between 2-5% (4) or one out of every 20-50 babies. 

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FASD does not appear in every person prenatally exposed to alcohol (5), and milder cases may not be recognized until children start school. Some of the effects are physical anomalies, low birth weight (LBW), organ defects, and intellectual disability (5). Researchers have not found a way to predict FASD based on timing or amount of drinking, other exposures, or any other factor. Some twins have "markedly different outcomes" (12) after developing together in the same uterus with the same exposure. The only effect that can be directly linked to alcohol exposure is the characteristic facial features, which are not present in every exposed infant, do not cause functional problems, and fade with age (5). All other outcomes can occur without alcohol exposure. 

Doctors have not agreed on a definition of FASD, and it is better understood as a spectrum of effects in many different body systems rather than a diagnosis like for cancer or the flu. It is a catch-all term that refers to a wide variety of effects that can occur with or without alcohol exposure. There are several different tools used by experts to evaluate and diagnose. Rates of a positive diagnosis among the different systems vary widely (13, 14). We can't be sure, because there is no nationwide data collection, but people of color are probably over-represented, even though white people drink more alcohol, because the facial comparison tools were developed using North American and Swedish faces, and there is only one system which also has a tool to assess Black faces. All groups are compared to either the white or Black tool. Finally, there is no biological test, there is no dose response*, no period of pregnancy with reduced risk (5), and therefore, no universal treatment protocol. Treatment is based on patient needs and does not depend of proof of alcohol exposure.

Many people who were exposed to alcohol and their birth and/or adoptive parents have identified the diagnosis as a source of stigma that is not necessary to receive services or helpful to understand their condition. It is particularly uncomfortable for birth mothers to self identify every time they seek care for their children. 

Some people question whether it is appropriate to use the diagnosis of FASD at all when doctors are not able to agree on what exactly FASD even means. We know that when we look at large numbers of people, if more of them drink, more of them will have these effects, but we can't say to an individual mother that her baby's condition is definitely caused by alcohol exposure, and we can't prove for sure that it's even related. 

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Despite the unknowns, we know enough to say that alcohol is not safe during  pregnancy, we just don't fully understand how the risk happens. Other than FASD, alcohol exposure also increases risk of miscarriage, stillbirth (5), and placental dysfunction - such as decreased placental size and impaired flow of blood and nutrients to the fetus(6). 

Chronic alcohol use by adults is associated with decreased absorption of nutrients, which can lead to the pregnant person experiencing deficiencies of many nutrients, including folic acid, which is important for fetal brain growth (1).