This study revealed a variety of knowledge levels and experiences related to alcohol consumption during pregnancy among Australian participants. Women and their partners were found to have differing views on the risk associated with consuming alcohol, and their evaluation of risk was impaired by conflicting advice and individual differences. In addition, women often reported that they had not received targeted advice or information from health professionals.
This research has indicated that most women and their partners recognise that alcohol has the potential to cause harm to the unborn baby. However, the quantity of alcohol required to cause harm, and the impact of the timing of the exposure were not as well known. Many women could not adequately describe the effects that alcohol may have on the unborn baby, and were more likely to believe that alcohol consumption is associated with physical birth defects and facial deformities which are caused by excessive alcohol consumption. Problems associated with brain development of the foetus, such as low IQ, behavioural issues, and learning difficulties, were mentioned by some participants although these were much less commonly reported by focus group participants. While FAS may be the most serious consequence of prenatal alcohol consumption, resulting in both physical deformities and developmental issues , it is important that women and their partners are aware of the initially invisible damages that can occur due to prenatal alcohol consumption. These adverse consequences of alcohol consumption during pregnancy often become visible later in life as the child may act out in school or display poor learning outcomes due to lack of attention and comprehension. Furthermore, alcohol consumption during pregnancy has the potential to cause damage throughout the continuum of pregnancy, not only in the first trimester. Therefore it is again of utmost importance that pregnant women are fully aware of the effects of alcohol consumption during pregnancy at all time periods.
Almost all of the participants believed that small amounts of alcohol were unlikely to cause harm, and were acceptable in pregnancy, particularly for a special occasion, and that the majority of harmful consequences were associated with excessive or binge drinking. They were correct in acknowledging that there is a lack of evidence about the effects of small to moderate amounts of alcohol ; however, it is important for woman to be aware that the risk is different for each individual woman and that a small amount has the potential to cause harm depending on a wide range of contributing factors .
Previous research has determined that health professionals often do not ask pregnant women about their alcohol consumption as they believe that most women already know not to drink alcohol during pregnancy, or believe that the information is not relevant for the individual woman in their practice . The current study highlights, that it was routine practice for health professionals to enquire about alcohol use at the initial booking appointment. However, participants’ responses clearly demonstrated that health professionals did not continue to assess the frequency and quantity of alcohol consumption at subsequent antenatal appointments. In order to ensure adequate information and support is provided to pregnant women and their partners, health professionals need to make certain that continuous enquiry about the quantity and frequency of alcohol consumption is undertaken, and to advise that drinking alcohol during the whole of pregnancy is recommended by national guidelines. Additionally, the findings of this study suggest that women and partners would like to have been given more information on why drinking in pregnancy is harmful by health professionals.
Another theme that emerged from the data and of which there is little previous research, is the issue of moderation. It was hard for several of the women in this study to avoid all of the foods and drinks that are not recommended during pregnancy, and this meant that some women would make concessions such as drinking alcohol but avoiding caffeine, or skipping both but eating soft cheese. It needs to be recognised that it is difficult for women to remove a lot of rewarding food and drink whilst pregnant, and that despite being informed of the risks of these substances, they may need help such as providing healthy alternatives (hard cheese, decaf coffee, mocktails etc.). There is limited existing research that explores the notion of moderation ; however, this issue has important clinical significance for health professionals who work with pregnant women and their partners, this would benefit from further exploration. Moreover, several participants felt that there was an overwhelming amount of information to process during pregnancy, particularly with regards to diet and nutrition; this was often very challenging to understand. This further highlights the need for health professionals to provide clear and concise information. This was expressed particularly by first time pregnant women, and there may be a significant difference in the information requirements needed by these expectant mothers when compared to others whom have experienced pregnancy previously.
Another interesting finding that emerged from the focus group discussions was the idea that drinking alcohol during pregnancy was a personal choice to be made by a woman. It was suggested that women would weigh up the benefits and risks and making an informed decision. The perception that it can be a personal choice conflicts with the consequences, as it is the developing baby who will be most affected by the decision and they have had no say in the decision to drink. This presents an ethical dilemma as the traditional practices of health care are based on principles of autonomy and beneficence; however, care for a pregnant woman can create a conflict between the rights of the woman and the rights of the foetus . It has been suggested that the ethical responsibilities of health professionals require that the best interests of the foetus be served, and research in the US has found that 95% (n = 847) of physicians felt that pregnant woman also have a moral responsibility to ensure the health of their unborn baby . On the other hand, it has also been suggested that pregnant women have the “right and responsibility to make informed decisions for herself and her foetus” . The complexity of this issue highlights the need for accurate and comprehensive information about alcohol consumption in pregnancy in order for women to be empowered to make healthy decisions. Moreover, it again emphasizes the demand for effective communication between pregnant women and health professionals in order to ensure that both the mother and foetus are receiving the best healthcare possible.
Continuing on from the idea of risk evaluation is the idea that alcohol can be used to relieve stress for the mother and this might outweigh the risk of harm to the baby. Women who are feeling anxious and stressed need to be clearly informed of the potential risks that alcohol may cause to the foetus. Women need to be provided with alternative strategies to manage any anxiety and stress. Further, midwives who might be currently promoting the use of alcohol for stress relief also need to be well informed of the potential harms of alcohol in pregnancy and the current NHMRC guidelines . Alcohol should not be recommended as a stress relief method in any population, particularly among pregnant women, and it might benefit midwives and other health professionals to have knowledge of referral pathways for services such as breathing and meditation, Cognitive Behavioural Therapy (CBT), and mindfulness. For example, resources such as MoodGYM are convenient and user-friendly tools that could be referred to by health professionals to help pregnant women who experience stress, anxiety and other mental health problems .
It was noted by participants in the study that health professionals, particularly midwives, might encourage the use of wine not only for stress relief, but as a benefit to the developing baby. This may be due to the limited scientific evidence that red wine may reduce incidence of heart disease ; however, no research to date has found that alcohol consumption improves the physical health of a developing baby, and it is recommended that pregnant women abstain from all types of alcoholic beverages . It was also discussed among participants that wine would be the most socially acceptable type of alcoholic beverage to consume during a pregnancy, especially in comparison to spirits and hard liquor. This is in keeping with previous research which has suggested that pregnant women were more likely to consume wine as their alcohol of choice . It is therefore important to convey the idea that all alcoholic beverages have the potential to cause harm in an unborn baby, and to ensure that health professionals, pregnant women, and the general public are clear that wine, beer and spirits can be equally harmful.
One of the most important findings of this study was the acknowledgement of the role of the partner in supporting women during pregnancy. Previous research has suggested that the partner may have a significant impact on a woman’s decision to drink during pregnancy, and that encouraging partners to decrease their alcohol use would help to decrease the woman’s alcohol use [18,29,30]. While the findings from the current study did not support the idea that a partner’s drinking habits would influence a woman’s alcohol consumption, it was noted that the partners were still supportive. For the participants in this study it was found that the women were unconcerned whether or not their partner cut back his alcohol use or continued to drink; however, it was important for the partner to provide support for the woman’s decision. This would suggest that future health campaigns do not necessarily need to focus on reducing the alcohol consumption of the partners, but focusing more on ensuring adequate levels of support for women, and an acknowledgement that the decision not to drink may be a difficult choice for pregnant women. From the partner’s point of view, the men in this study were supportive of their partner’s decision not to drink and had carefully considered reducing their own alcohol use.
There are several limitations that should be taken into consideration when interpreting the results of this study. The participants are not a representative sample of the larger population and therefore, the findings are not generalizable. A limitation of convenience sampling is the possibility that there may be an under-representation or over-representation of particular groups of people within the sample. The majority of participants were Caucasian and born in Australia. Therefore, other ethnic and cultural influences need to be taken into consideration. Secondly, due to the nature of focus group discussions there is a potential for bias as participants can sometimes feel peer pressure to provide a socially acceptable response, or may give similar responses.
Finally, due to cancellations one of the focus groups was attended by only 2 participants. This may have resulted in a more restrained discussion than other groups; however, it was agreed to include these participants so that the data generated from this discussion was not lost. It was thought that the responses from two participants would add to the volume of data generated from the other focus groups and would not undermine any of the conclusions drawn. Overall, the findings reflect the knowledge and views of the participants in this study and give an insight into the issues concerning alcohol consumption during pregnancy.
The findings from this research provide justification for improving the quality and consistency of information provided to pregnant women about alcohol consumption, as well as improving communication between women and their health professionals. It is clear that consistent, evidence based messages need to be promoted and need to address commonly held misconceptions, particularly around the quantity and timing of foetal alcohol exposure. This study highlights a need for continual discussions about alcohol consumption during pregnancy, which could be undertaken as a standard part of routine clinical practice, such as taking blood pressure or foetal heart rate monitoring at every appointment. Similarly, it is important to ensure that all pregnant women are routinely assessed for alcohol consumption and that the NHMRC guidelines are adhered too. Previous research has indicated that there may be significant barriers preventing health professionals addressing alcohol consumption with pregnant women. These include the assumption that most women do not drink much alcohol during pregnancy and that women already know not to drink, as well as issues such as: alcohol is not on the list of priorities during the antenatal consultation; the burden of consultation is already vast; and the perception that questioning women on their alcohol consumption could appear judgemental and cause anxiety or guilt . It is essential that barriers such as these are addressed, as routine assessment for alcohol consumption in pregnant women needs to be achieved.
This study also confirms the importance of shared decision making, and the role of partners and families in prenatal alcohol consumption. Despite an increase in knowledge and awareness of the adverse effects of alcohol consumption in pregnancy, the prevalence of FASD worldwide does not appear to be decreasing. Thus, while women remain central to FASD prevention, the inclusion of partners and families and a deeper understanding of the societal factors that influence a woman’s drinking may play a key role in tackling this important health issue.