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Prenatal alcohol exposure risks are serious but can be preventable.
For decades, alcohol has been recognised as a teratogen.
It crosses the placenta readily and can interfere with the development of all the organs and systems of the developing embryo and fetus.
Heavy prenatal alcohol exposure (PAE) is associated with a range of adverse obstetric and birth outcomes. PAE can also lead to fetal alcohol spectrum disorder, which is characterised by a diverse range of physical features and neurodevelopmental challenges.
However, risks pertaining to prenatal alcohol use are not clear-cut.
Not all episodes of PAE will lead to adverse consequences. There are complex genetic and epigenetic mechanisms at play, alongside variable individual and environmental risk factors that influence outcomes.
Although heavy alcohol use carries a higher likelihood of adverse consequences, the evidence for the risks of low level alcohol use is mixed.
Going beyond knowledge of risks: risk perceptions
Most people do have knowledge that prenatal alcohol can be risky. Risk knowledge, however, does not necessarily lead to behavioural change, as I explain in this video.
Individuals often have preconceived ideas about their own level of risk. These preconceived ideas, judgments and beliefs about risks form their risk perceptions about prenatal alcohol use. Unless perceived to be at risk, changing behaviour that brings pleasure such as alcohol use will be difficult or even perceived as unnecessary. Therefore, effective health communication hinges in part on successfully influencing an individual’s perception of risk. This has been shown in studies on the uptake of vaccines and on smoking cessation.
In our recent systematic review, three different dimensions of risk perceptions were identified: “am I at risk if I drink?” (susceptibility), “what is the impact of alcohol use on my pregnancy and baby?” (severity), and “how do I feel about alcohol use risks?” (emotion).
These different dimensions of risk perception were influenced by a range of factors.
Relevant to prenatal alcohol use are the characteristics of risk information and individuals’ interpretation of this information. Although the message that “women who are planning a pregnancy, pregnant or breastfeeding should not drink alcohol” is clear, individuals interpret the precautionary principle underpinning the advice (ie, no safe level of alcohol use have been found, hence women should not drink) differently. Some feel that the message was intended to protect the less educated individuals or provide an extra layer of protection to their babies. Others view it as a form of social surveillance or even an opportunity to educate individuals regarding the long term health risks of alcohol. Unless the message is perceived as credible, and risks perceived as real and related to the individual, the effectiveness of the precautionary approach to abstinence of alcohol use during pregnancy is limited.
Cultural and social landscapes also provide the context for individuals’ perception of risks. For example, occasional alcohol use during special occasions may be viewed as safe by some, but for others this may be frowned upon (here).
In addition, the circumstances surrounding an individual’s alcohol use are unique. Individuals may drink for a variety of reasons – stress relief, relaxation, or as a coping mechanism. For some, alcohol provides the refuge in the context of significant trauma such as domestic or family violence, addiction, or mental health challenges.
One size does not fit all
Individuals are not passive recipients of risk information.
They may apply harm reduction strategies to cope with the risk information; for example, drinking slowly or after a meal that was presumed to reduce the risk of adverse consequences. This means that every individual’s risk interpretation and behaviour are unique. Hence, the informational needs of individuals differ.
Understanding risk, how it is perceived, and the coping strategies adopted towards risk information is a crucial step towards creating programs and campaigns to raise awareness (here).
As most prenatal alcohol preventive messages and information have focused on influencing the expectant mother’s knowledge and choices, it is time to go beyond these generic messages and develop more targeted communication strategies.
These targeted strategies could focus on the different informational requirements. For example, some individuals may benefit from simple risk messages (no alcohol, no risk) while others may require more information regarding the available evidence about low to moderate level alcohol use. Some individuals may require information about practical strategies to manage alcohol use during social situations while others may need risk messages, strategies, and appropriate supports to cope with the underlying issues of trauma, addiction, or mental health difficulties.
As risk perception is contextual, individuals may also be more receptive and relate better to risk messages that reflect their cultural values and social environment.
For many individuals, coping with the risks related to prenatal alcohol use is not as simple as stopping alcohol consumption. Acknowledging their emotional journey can help influence their decisions in a personal and motivationally relevant way.
Hence, effective prenatal alcohol use health communication should be a two-way partnership. As advocated by Brown, “communication strategies should take account of variation in mothers’ information needs and should seek to align with the [intention of the] broader communication [agenda]”.
The challenge therefore is for us to embrace a coordinated and tailored health communication strategy.
Communication strategies must be take individual contexts such as sociodemographic factors, life stressors, coping mechanisms, experience of stigma, mental health status, and motives of alcohol use into consideration (here and here).
At the same time, the message must be grounded in scientific knowledge and transparent about the uncertainty of evidence.
These efforts would guide individuals towards informed decision making and appropriate harm reduction strategies.
May Na Erng is a PHD candidate in the Faculty of Medicine at the University of Queensland.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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To the previous replies. As noted in the article, publice health messaging is complex and the ‘one size fits all’ approach isn’t the most effective. The national Every Moment Matters and Strong Born campaigns have been delivered across 4 targeted streams for exactly these reasons.
Research in animal models demonstrates that just ONE standard drink affects the brain. Studies have also been released about the impact of one standard drink making changes to facial structure in human fetuses. It isn’t of course possible to trial alcohol volume levels on pregnant women and as mentioned earlier, there are a number of environmental and genetic factors which mean the impact is different for both the mother and fetus.
It is not yet possible to determine a minimum level, hence the message is zero. For greater consideration is ‘our’ social acceptance of alcohol and lack of public awareness around the risks prior to pregnancy recognition. Women want and need to know the facts to be able to make informed decisions.
I am a mother, a professional educated woman who used alcohol socially to relax and unwind every Friday night after a stressful work week. I fell pregnant the first time we tried, I didn’t change my alcohol intake until I realised with surprise at 6 weeks that I could be pregnant. Our son would have been exposed to alcohol on approx. 3 to 4 occassions. Binge drinking, 4 standard drinks or more. I only drank on a Friday night. I was healthy, ate well, had good mental health, didn’t smoke or use other substances. I avoided soft cheese, washed my salads and limited my caffeine to one weak coffee a day. Importantly, there was no trauma in my life, past or present. Our son was born full term, 9 lb, and met all developmental milestones. And yet, after many years of challenges raising are amazing son, at 14, we finally received a diagnosis of FASD. My drinking pattern would have seemed low to moderate to many of my peer group. The damage was done BEFORE I knew I was pregnant. This is why the public health messaging MUST be, to cease alcohol intake, from the moment you start trying.
Can I encourage anyone reading this article or the comments to use your preferred search engine to explore resources and support at NOFASD Australia, Every Moment Matters and Strong Born.
“the evidence for the risks of low level alcohol use is mixed.” bit of an understatement if you ask me. More like nonexistent. An inconvenient truth that many in the no alcohol camp try to gloss over.
Jane Andrews is correct. Absolutist messages like “no amount of alcohol in pregnancy is proven to be safe” just reinforces anxiety – on top of the many other pressures that currently plague mothers. It’s not much more useful than saying “no amount of breathing air is proven to be safe” – because even breathing, eating and drinking come with risks.
It’s not helpful to aim for zero risk in human life.
The real problem with most of the research on this topic is that there is very little data on very low alcohol consumption during pregnancy – say, ten grams per week or less. Most studies define “low” consumption as less than ten grams per DAY.
The further the recommendations diverge from valid evidence, the less credibility they hold as public health messages.
If women could be told that half a glass (5 g) of alcohol once a week or less has not been shown to harm the foetus, perhaps we will be more likely to embrace this sort of limit rather than being castigated as naughty girls.
I think one of the issues – as a Dr practising for >35 years and being a mother of 3 children myself – is the conflation here and in much of the info about alcohol and pregnancy between ANY alcohol consumption and HEAVY consumption.
We are reinforcing the “worried well” problem: anxious people attending to the non-nuanced message think there is huge risk from single glasses of wine – whereas others, for whom the message might be more important, either don’t get the message, don’t see it as relevant for them, simply tune out or have far greater health and psychosocial issues on their plates – like major disadvantage, DV, homelessness, addiction….
heavy PAE should have the abbreviation HPAE if that’s what we need to address AND it needs to be done in the context of the drivers of HPAE – and low level, responsible consumption should be left out of the “panic” messaging.