We show it is important to consider factors like the environment and parents’ mental health when trying to understand associations between prenatal alcohol exposure and child outcomes – it is not as simple as “cause and effect”. Women who drink alcohol DURING pregnancy tend to be wealthier and better educated, yet children's developmental problems related to alcohol use seem to be more concentrated in groups facing adversities such as poverty and mental illness. A laser focus on pregnant women's use of alcohol may overlook related problems, all of which affect the future child. Greater access to mental health care, such as that embedded in obstetric services, could help address problematic alcohol use as well as psychological symptoms and distress, helping women and the next generation.