The effects of maternal alcohol consumption on the developing fetus have been documented since recorded history, however, it is only during the last four decades that scientific evidence has confirmed alcohol as a teratogen with direct links to neurodevelopmental disorders (Jones and Smith, 1973). Concerns about alcohol use during pregnancy relate to the outcome of Fetal Alcohol Syndrome (FAS) a serious condition associated with heavy alcohol use and binge drinking, particularly in early pregnancy. Infants born with this condition display an array of deficits including: characteristic facial malformations, brain and central nervous system disorders, growth retardations; heart and kidney defects, hearing and eyesight impairments, skeletal defects and immune deficiencies (Stratton, Howe & Frederick, 1996; National Institute of Alcohol and Alcoholism, 1997). More recently, concerns about alcohol use during pregnancy have extended to Fetal Alcohol Spectrum Disorder (FASD) which is associated with lower level alcohol use during pregnancy. This disorder describes a range of adverse effects including neurobehavioural deficits which become more overt and have greater quality of life impact over time (Elliott & Bower, 2007; Henderson, Gray, & Brocklehurst, 2007; Burden et al, 2005; Ontario Maternal, Newborn and Early Child Development Resource Centre et al, 2005; Streissguth & Dehaene, 1997).
Interest in poor outcomes associated with lower level use of alcohol during pregnancy has resulted in policy debate in Australia and internationally. The United Kingdom and New Zealand have recently modified policy to provide more stringent advice to women who are considering becoming pregnant, who are pregnant and/or who are breastfeeding (United Kingdom Department of Health, 2007; Alcohol Advisory Council of New Zealand, 2007). This policy advice is reflected in nine of the other eleven national policies documented by the International Center for Alcohol Policies (International Center for Alcohol Policies, 2007). The more lenient Australian Guidelines are now in a minority, along with those of Ireland and Switzerland.
As guidelines for the consumption of alcohol during pregnancy become more supportive of non-use, there is an increasing need for interventions to assist those who may find it difficult to reduce alcohol consumption. Evidence-based interventions need to include information from the target audience in the early stages of intervention development to ensure that strategies and methods are appropriate, useful and resonate with the target audience (Holman, 1996).
The Alcohol Use During Pregnancy – Formative Intervention Research Study is an explorative, descriptive study using both quantitative and qualitative methods. The study is designed to assess factors that contribute to alcohol consumption during pregnancy, and to identify potential intervention strategies to reduce alcohol consumption during pregnancy. The study targets pregnant women who attend public hospitals in Perth, Western Australia, and who are in their second or third trimester of pregnancy. Participants have identified themselves as current alcohol drinkers, 18 years of age or older, and who have English as their primary language.
It was planned that two forms of data would be collected as part of the study; focus group data (qualitative), and survey data (quantitative and qualitative). However after several months, focus groups as a data gathering method, were cancelled due to the lack of response from pregnant women attending the study hospitals. Over a 14 month period between October 2006 and December 2007, 144 self-completion surveys were returned to the study researchers. Surveys assessed: the demographics of women who consume alcohol during pregnancy; their pregnancy history/ies; past and current alcohol consumption; and a series of questions to assist in identifying context and issues related to alcohol use during pregnancy which will assist in identifying potential intervention targets and strategies.
Research Activity to Date
The results presented in this report are largely frequency results of survey variables. Future analysis will provide a more detailed understanding to the relationship between dependent and independent variables and the contribution that they can make to future interventions. Future analysis will be documented in reports and scientific publications.
Main Findings to Date
As with the maternal demographics of women in Western Australia (WA) generally (Gee, Hu &Ernstzen, 2006), the majority of women in this study (approximately 60%) were between the ages of 25 and 35 years when they were pregnant, with an age range of between 15-44 years, compared to 12-45 years of age in WA generally. The study group was also similar to WA women as a whole, in that approximately 91% were married or in a de-facto relationship and approximately 7.5% were single.
The demographic findings of the study show a group of women with a range of lifestyles. A small number of women (16.3%) in the study group reported a low income of $30 000 or below, with a fifth of the study group having a Government Health Care Card. The majority of study women were from households with an annual income of between $45 000- $90 000.
Under half of the women in the study (41.5%) were in their first pregnancy and this reflects the Western Australian average where 41.9% of recorded births were of first time mothers (Gee, Hu &Ernstzen, 2006). Early results indicate that some women, during second and subsequent pregnancies, are less likely to feel the need to abstain from alcohol, partially as a response to previous positive outcomes for the own, and their friends’ pregnancies and infants.
The proportion of women consuming alcohol to risky levels in the 12 months prior to becoming pregnant (48.6%) was higher than the proportion of women who consumed alcohol to risky levels while pregnant (9.9%). This raises two issues related to potential interventions. The first indicates a need for intervention during the preconception period, as recent research suggests that preconception health and lifestyle issues can play a part in postnatal outcomes (Centres for Disease Control and Prevention, 2008; Freda, Moos, & Curtis, 2006). The second issue indicates that a small group of high risk women may require intensive intervention during pregnancy to reduce levels of risky consumption and subsequent potential for adverse postnatal outcomes.
The proportion of women consuming alcohol to within the Australian Alcohol Guidelines varied between the 12 months prior to pregnancy and pregnancy, with a similar trend towards reduction as demonstrated in the risky drinking data. Eighty six (60.6%) women consumed beer in the 12 months prior to pregnancy with 60.5% of these women drinking beer in moderation. Fifty one (35.9%) women continued to consume beer while pregnant with 88.2% of these women drinking beer in moderation. One hundred and seven (75.3%) women consumed wine in the 12 months prior to pregnancy, with 62.6% of these women drinking in moderation. Seventy eight women continued to consume wine while pregnant (54.9%), with 97.4% of these women drinking wine in moderation. One hundred and two (71.8%) women consumed spirits in the 12 months prior to pregnancy with 53% of these women drinking in moderation. Forty four (31%) women continued to consume spirits while pregnant, with 79.5% of these women drinking spirits in moderation.
The most common settings for alcohol use by study women was in private venues, either their own home (67.7%) or at a friend’s houses (15.4%). Study women were less likely to drink at public settings such as at restaurants (8.5%) or in pubs or bars (6.9%). Study women most commonly associated with partners (58.1%) and friends (31.8%) during a drinking occasion. A small proportion of women also chose to drink alone (5.4%). Interestingly, nearly three quarters (72.3%) of the women initiated a drinking session on most occasions, with friends and partners initiating a drinking occasion less often (16.2% and 10.8% respectively). The private nature of most alcohol consumption by pregnant women, and that women themselves initiated alcohol consumption on most occasions, provides important information to assist in defining the form and targets of potential intervention. There is clearly a greater need to develop specific interventions that target the individual, both pregnant women themselves and their family and friends, that go beyond those provided by their antenatal health care professional.
Most commonly obstetricians and other health professionals are suggested as avenues for intervention to reduce alcohol use during pregnancy (Elliot & Bower, 2008). However, most obstetricians (95.2%) (Australian data) do not provide advice consistent with NHMRC guidelines and less than half do not ask about alcohol use during pregnancy (NHMRC: 2001). A higher rate of obstetrician or health carer intervention was reported by the women involved in this study, with seventy percent reporting being asked about their alcohol consumption, and over a half (54.8%) receiving some form of advice about their alcohol consumption during pregnancy, including 29.6% who were advised not to drink while pregnant, and another 4.2% who were advised that the occasional drink was OK.
The variation in obstetrician and health professional advice to women about alcohol during pregnancy indicate that other methods, in addition to refined obstetrician/health carer intervention, which target site and situation of drinking, may be important to generate change.
This initial analysis of study data provides some insights into intervention targets, components and strategies that may be useful to guide future interventions aiming to reduce alcohol consumption during pregnancy. The next phase of the analysis will assess the relationship between dependant and independent variables as well as data specific to subgroups within the study, and will further assist in defining and directing intervention planning.
A useful conceptual tool or framework to guide intervention direction and focus is Holder’s (1989) Alcohol Prevention Conception Model which defines levels of intervention activity including: the Legal and Cultural Environment; the Community Environment; the Family and Workplace Environment; the Immediate Drinking Environment; and Individual Factors. This framework can help health planners develop a series of well considered interventions, targeting each strata in the framework, to increase the potential impact of interventions to reduce alcohol consumption during pregnancy.
Exposure to alcohol during the prenatal period remains the leading cause of preventable birth defects and developmental problems in Australia and as such has generated increase attention from policy, research and health practitioners. A large proportion of women reduce or stop alcohol use when they find out that they are pregnant, however, there is a proportion of women who continue to drink in moderation, and an additional group who continue to drink to risky levels while pregnant. It is these two groups that should be the focus of intervention research, and in particular formative research with Australian women to determine potential intervention targets, strategies and components that resonate with Australian women.