A federal agency earlier this month issued a warning for women of child-bearing age: Avoid alcohol if you're sexually active and not using birth control, because you might be pregnant and alcohol can harm a fetus.
The intention was to give women information about choices that affect health.
But the recommendation from the US Centers for Disease Control and Prevention unleashed a barrage of ridicule and fury, as bloggers and commentators denounced it as sexist, patronizing, and alarmist. Even "The Late Show with Stephen Colbert" took a few moments to lampoon a graphic that accompanied the advisory — a likely first for a CDC alert.
The backlash surprised a leader of the campaign, Dr. Anne Schuchat, the health agency's principal deputy director. In a recent interview, Schuchat said she was worried the brouhaha had distracted from an important message.
The uproar illustrates the challenges of encouraging healthy behavior without seeming judgmental, especially when the advice touches on women's freedom to make choices in pregnancy and childbirth.
In issuing its advisory, the CDC sought to draw attention to the early weeks when women don't yet know they're pregnant, a time that can be crucial to fetal development.
Exposure to alcohol in the womb can lead to "fetal alcohol spectrum disorder," estimated to affect to 2 to 5 percent of children in varying degrees of severity. Symptoms can include abnormal facial features, small head size, short stature, and lifelong intellectual and behavioral difficulties. Because these dangers are well-known, 90 percent of women don't drink once they know they're pregnant.
The CDC's advisory was prompted by new research showing that 3.3 million women between the ages of 15 and 44 are drinking alcohol, having sex, and not using birth control. Especially concerning, it also found that three-quarters of women trying to get pregnant do not stop drinking.
"Fetal alcohol spectrum disorder is serious. It's common. It's 100 percent preventable," Schuchat said. "The intent is to reduce the number of children with that difficult condition."
Critics attacked the CDC for placing all the burden on women, with no mention of men's role. They accused the agency of treating women as nothing more than potential vessels for fetuses. They questioned whether drinking was a greater risk to fetuses than, say, getting in a car or a hot tub. Some disputed the scientific validity of the advice, given that it is not known how much alcohol it takes to damage a fetus.
"Women are constantly being told what to do," Rupali J. Limaye, a research director at Johns Hopkins Center for Communication Programs, said in an interview. The CDC's message made sense, she said, but it came across as, "Hey women, here's just another way we're going to think about restricting your freedom."
Perhaps the biggest source of the CDC's troubles was a much-ridiculed informational graphic, which Schuchat acknowledged was pushed through without enough thought. Titled "Drinking too much can have many risks for women," the graphic lists these risks for "any woman" who drinks: injuries/violence, heart disease, cancer, sexually transmitted diseases, fertility problems, unintended pregnancy.
"Alcohol does not beat or impregnate women," writer Darlena Cunha observed in Time. "Men do."
As chronicled by the website BuzzFeed , the CDC later changed the graphic to say those risks are "for anyone" and added a drawing of a man. Soon after, the graphic was gone altogether.
Vish Viswanath, professor of health communication at the Harvard T.H. Chan School of Public Health, called the CDC's approach "a classic failure in translation." The agency should have been more aware of how its advice would be received "especially at a time when many women feel that they are under attack . . . when reproductive rights are being attacked."
The CDC focused on women alone, without addressing such issues as the availability of reproductive health services, alcohol marketing, and the role of men. "It's like the rest of society doesn't have responsibility for this, except for this group of women," he said.
Schuchat agreed women deserve support in having a healthy pregnancy. But she said men's drinking, while it can affect their sperm count, has not been linked to fetal alcohol spectrum disorder. And in the end, she said, "Women are still the ones that get pregnant."
Schuchat noted that over the decades, new information has emerged about pregnancy risks, adding burdens on women. "The changes are reflective of more data rather than different attitudes about women and their empowerment," she said.
Dr. Daniela Anne Carusi, director of surgical obstetrics at Brigham and Women's Hospital, said she was surprised by the CDC's alert. "They stated it so strongly that it implies strong evidence to back it. That's not true," she said. "It's likely that some level of alcohol is safe, but we don't know what it is."
Alcohol is a particularly sensitive issue, Carusi noted. No one would chastise a pregnant woman at a sushi bar, even though doctors advise against eating raw fish during pregnancy. But strangers will berate the same woman if she is seen holding a glass of wine, she said.
Still, the CDC's advice is hardly far afield. In 2005, the surgeon general advised "pregnant women and women who may become pregnant" to abstain from alcohol. In 2011 and again in 2013, the American College of Obstetricians and Gynecologists backed that advice. In October 2015, the American Academy of Pediatrics declared that no amount of alcohol should be considered safe at any stage of pregnancy.
Neither the CDC nor the medical groups advise terminating a pregnancy if a woman who has been drinking discovers she is pregnant, and doctors routinely tell women in that situation not to worry. For any individual woman, the risk is low that a fetus will be harmed by an occasional drink.
But certain pregnancies might be affected because of genetic susceptibilities in the mother or child. "In some individuals there may be exquisite sensitivities," Schuchat said.
Dr. Michael E. Charness, a Harvard neurologist who studies the effects of alcohol on the nervous system, urges women to weigh the risk of fetal harm — even if that risk is small — against the transient pleasure of drinking. Although definitive studies in people are lacking, other findings are ominous, he said: Small amounts of alcohol have damaged cells in the laboratory, and animal studies could not identify a safe level of alcohol.
"I view this as a way to empower women to make healthy choices," Charness said, "to make their own decisions for their unborn children."