Communications about prenatal alcohol exposure risks 'must be targeted'

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.