Acquisition and Utilization of Information About Alcohol Use in Pregnancy Among Australian Pregnant Women and Service Providers

Trapped in a maze: A meta-ethnography of women's experiences of alcohol use in pregnancy

INTRODUCTION

Despite the recognized link between prenatal alcohol consumption and various congenital anomalies, the negative consequences for women's own health and family health, as well as the work done in healthcare to prevent alcohol in pregnancy, the acceptance of alcohol use during pregnancy persists in numerous communities around the world. Knowledge about women's alcohol use in pregnancy and how it relates to the social and cultural context they are part of is important to help and support women in abstaining during pregnancy. This meta-ethnography aims to offer a novel interpretation and conceptual understanding of the experiences of women who consume alcohol during pregnancy by synthesizing insights from existing qualitative studies.

METHODS

An interpretative meta-ethnographic design was chosen based on a systematic literature search in seven electronic databases, and manual searches were conducted in 2023. The CASP checklist was used to assess the 18 included articles.

RESULTS

In the synthesis, we use the metaphor of being trapped in a maze to illustrate the complexity of pregnant women's experiences of drinking during pregnancy. Women who drink alcohol during pregnancy are navigating the maze in a whirlwind of conflicting information and knowledge. The findings show how sociocultural norms form rigid pathways within the maze. In relation to their sociocultural context, women use several motives to justify the routes chosen within the maze. The competing information, knowledge and clashing norms within women's sociocultural contexts leave women to navigate alone in the maze.

CONCLUSIONS

Alcohol in pregnancy needs to be conceptualized as an issue positioned at the intersection of social sciences and healthcare and needs to be handled accordingly, both through transdisciplinary research, by early prevention and multimodal interventions in healthcare and the broader society. Such interventions would benefit from drawing on knowledge about women's experiences with alcohol in pregnancy.

Reporting on Health Care and Social Service Provider Approaches to Promoting Alcohol Abstinence During Pregnancy

Despite the known detrimental health effects of alcohol use during pregnancy, there are still health care (HCP) and social service providers (SSP) who do not promote complete abstinence. The purpose of this study was to explore the current practices of HCPs and SSPs when discussing alcohol use during pregnancy, and to understand their rationale for their specific recommendations. An online survey was completed by 1123 HCPs (n = 588) and SSPs (n = 535) that asked them to identify their approach to discussing alcohol and pregnancy. Participants had the option to further explain their current recommendations regarding alcohol use during pregnancy in an open-ended format. Open-ended responses were analyzed using a content analysis approach (n = 156). The majority of respondents recommend abstinence (83.9% of HCPs, n = 493; 78.4% of SSPs, n = 419), while 9.8% of HCPs (n = 57) and 2.2% of SSPs (n = 12) responded that low levels of consumption may be acceptable. HCPs may recommend low levels of consumption based on other international guidelines, limited evidence to suggest that one unit of alcohol is harmful, and as a harm reduction strategy. SSPs stated that they refer clients to HCPs for recommendations related to alcohol consumption, and that they prefer to provide information based on public health guidelines. This exploratory work may inform the development of resources to support HCPs and SSPs to recommend abstinence from alcohol throughout gestation.

Opening Pandora's box: A meta-ethnography about alcohol use in pregnancy from midwives' and other healthcare providers' perspectives

INTRODUCTION

Alcohol consumption has increased in recent years, including among women of childbearing age. A woman's alcohol intake during pregnancy is linked to complications and injuries in the newborn, and the risk of the child being harmed by the mother's alcohol use increases in proportion to the amount of alcohol she consumes. This meta-ethnography aims to explore midwives' and other healthcare providers' experiences of screening pregnant women for alcohol use in pregnancy and counselling them on the subject.

METHODS

A systematic literature search in CINAHL, Maternity & Infant Care, MEDLINE, and Scopus was conducted in August 2021 and updated in January 2023. The CASP checklist was used to assess the included articles and meta-ethnography was used to synthesize the data.

RESULTS

Fourteen qualitative studies were included. In the synthesis, we use the metaphor of Pandora's box to deepen our understanding of the topic. We found that some healthcare providers tiptoe around the box, not wanting to face the consequences and responsibilities of asking women about their alcohol use. Others refuse or are reluctant to open the box because they lack knowledge about screening and counselling. Some eventually open the box, understanding the importance of establishing a trusting relationship to address alcohol use and seeing the need for knowledge and screening tools.

CONCLUSIONS

Healthcare education has the important task of ensuring that healthcare personnel have sufficient evidence-based knowledge about alcohol use in pregnancy. In the future, a health-promoting, tailored approach offering women in pre-pregnancy and early pregnancy sufficient evidence-based information should be implemented.

Perceptions of two different alcohol use behaviours in pregnancy: an application of the prototype/willingness model

Objective:

This study explored whether exposure to either an ‘ambiguous consumption’ prototype (no amount of alcohol specified) or a ‘small consumption’ prototype (‘small’ amount of alcohol specified) had an impact on prototype perceptions of, and willingness to use, small amounts of alcohol during pregnancy.

Method:

Participants were 140 women living in the UK, aged 20–45 years old, of whom 92% had previously been, or intended to become, pregnant. Participants completed measures to assess how favourably they viewed alcohol use in pregnancy, how similar they felt to those who would use alcohol in pregnancy and how responsible they perceived those who would use alcohol in pregnancy to be. Participant’s own willingness to use small amounts of alcohol during pregnancy was also assessed.

Results:

Having at least one child was positively correlated with being willing to accept an alcoholic drink while pregnant for those exposed to the ‘ambiguous consumption’ prototype only. Although perceptions of favourability, similarity and responsibility were consistently higher for those exposed to a ‘small consumption’ condition, there were no differences in willingness to drink according to exposure.

Conclusion:

This research suggests that women’s perceptions of those who drink alcohol while pregnant differ according to the amount of alcohol that they perceive as typical. This may have implications for how alcohol use in pregnancy is portrayed in public health messaging, particularly regarding the level of acceptance that may be associated with low to moderate alcohol use.

Why do women consume alcohol during pregnancy or while breastfeeding?

Issue

Alcohol consumption during pregnancy and breastfeeding cause adverse health outcomes to the mother and child, including Fetal Alcohol Spectrum Disorder (FASD).

Approach

Systematic literature review and thematic synthesis. Original studies that contained reasons for alcohol consumption in pregnancy and while breastfeeding were included. The Mixed Methods Appraisal Tool (MMAT) and the Confidence in the Evidence of Reviews of Qualitative Research (CerQUAL) approach were utilised. The review protocol is available on PROSPERO (registration number: CRD42018116998).

Key Findings

Forty‐two eligible studies comprising women from 16 countries were included. Most commonly reported reasons of alcohol use in pregnancy were societal pressure and the belief that only “strong” alcohol and alcohol in large quantities is harmful. Other reasons were: a lack of awareness of adverse effects on the fetus; coping with adverse life experiences; consumption based on intuitive decision‐making and influenced by personal/peer experiences; belief in the beneficial properties of alcohol; advice from medical practitioners; unwanted or unplanned pregnancy; alcohol dependence; and consumption as a cultural/traditional custom. Reasons for alcohol use during breastfeeding included the belief that alcohol stimulates breast milk production, unclear advice from medical practitioners, unawareness of the risks of infant exposure and to improve mood and celebrate events.

Implications

Understanding the context of reasons for alcohol use in pregnancy is crucial for implementing prenatal health education, and preventing FASD and other adverse maternal and child health outcomes.

Conclusion

Individual beliefs, knowledge/advice, culture and personal circumstances influence alcohol use in pregnancy. Data are limited for reasons surrounding alcohol use while breastfeeding.

Is 'a little' too much?: An exploration of women's beliefs about alcohol use during pregnancy

OBJECTIVE

Interventions to address alcohol use during pregnancy need to target underlying determinants of the behaviour. Using the theory of planned behaviour as a theoretical framework, the aim of this study was to identify behavioural, normative and control beliefs regarding alcohol use during pregnancy among a sample of women. Design: 435 women completed a 15-minute online questionnaire designed to identify beliefs about alcohol use during pregnancy. Data were categorised according to type of belief and then summarised and described. Results: The majority of respondents saw few advantages of consuming alcohol during pregnancy and believed that most people would disapprove of alcohol use during pregnancy. Although most women endorsed alcohol abstinence during pregnancy, views on the perceived risk of different levels of alcohol use and perceptions of the 'typical' person who drinks while pregnant varied between participants. Conclusion: This work contributes to the understanding of women's beliefs about alcohol use during pregnancy. Future research should explore how women's beliefs inform their decision making about different levels of alcohol use in pregnancy. Additionally, further research or messaging about alcohol use in pregnancy must also consider the potential for contributing to stigmatising beliefs.

Community Priority setting for Fetal Alcohol Spectrum Disorder Research in Australia

INTRODUCTION

Fetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental disorder caused by prenatal alcohol exposure (PAE). FASD research is a rapidly growing field that crosses multiple disciplines. To ensure research is relevant and meaningful for people living with FASD, their families, and the broader public there is a need to engage community members in setting priorities for research.

OBJECTIVES

Our primary objective was to formally identify the views of people living with FASD, their parents/caregivers, service providers, and the general community on the research priorities for FASD and alcohol use in pregnancy in Australia. Our secondary objective was to provide an overview of current research in the highest priority areas identified.

METHODS

The approach for this study involved two community surveys and a consensus workshop, followed by a rapid literature review. Survey responses (n = 146) were collected and grouped using qualitative thematic analysis. The themes identified were then ranked in a second survey (n = 45). The 22 highest ranked themes were considered in a workshop with 21 community members, and consensus on the top ten priority areas was sought. The priority areas were grouped into conceptually similar topics and rapid literature reviews were undertaken on each.

RESULTS

A diverse range of priorities was identified within key areas of prevention, diagnosis, and therapy. On request from participants, separate priority lists were developed by Aboriginal and non-Aboriginal participants.

CONCLUSION

There is need for a national network of researchers to take forward the research commenced by the Centre of Research Excellence, FASD Research Australia, in addressing community priorities.

KEY WORDS

Community, priorities, FASD, rapid review, Australia.

Determinants of Women's Drug Use During Pregnancy: Perspectives from a Qualitative Study

INTRODUCTION

Drug use during pregnancy can have negative effects on maternal and child health. However, there is a dearth of data regarding drug use among pregnant women in Kenya, where illicit drug use is on the rise. In this paper, we report factors influencing women's decisions to use drugs during pregnancy.

METHODS

In 2015, we conducted in-depth interviews and focus group discussions with 45 women who inject drugs and five key stakeholders involved in provision of services to people who use drugs in coastal Kenya. Inductive thematic analysis was conducted to draw out themes related to key determinants of drug use during pregnancy.

RESULTS

Four key themes emerged outlining determinants of drug use during pregnancy: (i) the use of drugs to cope with the stress of unexpected pregnancy, (ii) the continued drug use during pregnancy to manage withdrawal, (iii) the dual effect of pregnancy on drug use either as a facilitator or as a moderator of drug use, and (iv) the role of male intimate partner in influencing women's drug use during pregnancy.

CONCLUSION

Our paper reports women's drug use during pregnancy and the factors influencing this phenomenon. To safeguard the health and well-being of pregnant women and their unborn children, there is a need for education and awareness raising, implementing couple-based harm reduction approaches to leverage on positive male influences, improving availability of drug treatment, and provision of family planning interventions for women who use drugs.

Pregnancy as a transition: First-time expectant couples' experience with alcohol consumption

Introduction and Aims

Most official healthcare guidelines apply the precautionary principle by recommending that pregnant women abstain from any alcohol consumption. However, a number of women continue drinking alcohol while pregnant. The aim of this study was to investigate couples′ experiences of the issue of alcohol consumption during pregnancy as a transitional process.

Design and Methods

Thirty semi‐directive joint interviews were conducted with couples expecting their first child in Switzerland. Interviews were analysed thematically with the help of ATLAS.ti.

Results

Couples endorsed the imperative of changing drinking habits and all the women reduced their alcohol consumption, although some reported difficulties. First, we identified three themes describing how couples experienced the woman′s change of drinking habits as a smooth transition: Internalisation of risk discourses, abstinence as a social norm and embodiment of alcohol aversion. Second, we emphasised four kinds of difficulties that couples encountered in their everyday lives: burden of risk discourses, conflicting advice, social occasions and desire for alcohol.

Discussion and Conclusions

This paper makes a significant contribution by examining prenatal drinking change as a transition. In this conceptualisation, the change of alcohol consumption is a relational process that is shaped by multiple changes and social norms. Our findings have important implications for practice. First, health professionals should be aware of the difficulties women experience when they abstain from alcohol during pregnancy. Second, our findings suggest the importance of a patient‐centred approach that considers the role of the partner in supporting a pregnant woman′s change of alcohol consumption.

Has a national policy guideline influenced the practice of raising the topic of alcohol and breastfeeding by maternal healthcare practitioners?

Globally, the public health recommendation for exclusive breastfeeding to the first 6 months of life is not being achieved by many low- and middle-income countries. Many factors have been determined to affect the early cessation of breastfeeding; however, little attention has been paid to the role of alcohol, an increasingly favoured commodity, particularly in these Westernised nations. Maternal healthcare practitioners play a pivotal role in a woman's breastfeeding journey by providing timely advice that can help support continued breastfeeding. Maternal healthcare practitioners (MHP) from across Australia were invited to take part in a semi-structured telephone interview (n = 19) to elicit their knowledge of a national alcohol policy guideline on alcohol and breastfeeding, their confidence to provide information on this topic, and if they were routinely incorporating conversations on alcohol and breastfeeding into their practice. The results affirmed that the majority of MHP were not aware of the national policy providing direction for safely consuming alcohol during lactation and were not incorporating this information into their practice. This study suggests having a national policy guideline for safe alcohol consumption during lactation has not promoted awareness of this topic among MHP as a potential strategy to support long-term breastfeeding duration.

Exploring practices and perceptions of alcohol use during pregnancy in England and Sweden through a cross-cultural lens

Background

Qualitative studies have aimed to understand why some women continue to drink during pregnancy; however, there is a lack of comparative cross-cultural research. We aimed to explore perceptions and practices of alcohol use during pregnancy in England and Sweden.

Methods

Semi-structured interviews were conducted with 21 parents in Merseyside, England and 22 parents in Örebro County, Sweden. Interviews were audio recorded, transcribed verbatim and translated. Data were analyzed using thematic analysis.

Results

The majority of women in both countries abstained from alcohol when they found out they were pregnant, despite alcohol being part of many social contexts before pregnancy. Nine of the seventeen English women drank at some point during pregnancy, typically on special occasions. Most parents felt women should modify their alcohol intake when they become mothers, though several English parents argued that responsible motherhood did not necessarily equate to abstinence. Swedish parents held strong opinions against drinking during pregnancy and argued that any amount of alcohol could harm the foetus. English parents' opinions were divided; some were skeptical of whether low to moderate drinking was associated with risks.

Conclusions

Practices and attitudes towards alcohol use during pregnancy and views on foetal rights and responsibilities of pregnant women differed in England and Sweden. Shared social norms around drinking may be shaped within the policy context of pregnancy drinking guidelines, determining whether women consume alcohol or not.

A practice change intervention to improve antenatal care addressing alcohol consumption by women during pregnancy: research protocol for a randomised stepped-wedge cluster trial

Background

Despite clinical guideline recommendations, implementation of antenatal care addressing alcohol consumption by pregnant women is limited. Implementation strategies addressing barriers to such care may be effective in increasing care provision. The aim of this study is to examine the effectiveness, cost and cost-effectiveness of a multi-strategy practice change intervention in increasing antenatal care addressing the consumption of alcohol by pregnant women.

Methods

The study will be a randomised, stepped-wedge controlled trial conducted in three sectors in a health district in New South Wales, Australia. Stepped implementation of a practice change intervention will be delivered to sectors in a random order to support the introduction of a model of care for addressing alcohol consumption by pregnant women. A staged process was undertaken to develop the implementation strategies, which comprise of: leadership support, local clinical practice guidelines, electronic prompts and reminders, opinion leaders, academic detailing (audit and feedback), educational meetings and educational materials, and performance monitoring. Repeated cross-sectional outcome data will be gathered weekly across all sectors for the study duration. The primary outcome measures are the proportion of antenatal appointments at ‘booking in’, 27–28 weeks gestation and 35–36 weeks gestation for which women report (1) being assessed for alcohol consumption, (2) being provided with brief advice related to alcohol consumption during pregnancy, (3) receiving relevant care for addressing alcohol consumption during pregnancy, and (4) being assessed for alcohol consumption and receiving relevant care. Data on resources expended during intervention development and implementation will be collected. The proportion of women who report consuming alcohol since knowing they were pregnant will be measured as a secondary outcome.

Discussion

This will be the first randomised controlled trial to evaluate the effectiveness, cost and cost-effectiveness of implementation strategies in improving antenatal care that addresses alcohol consumption by pregnant women. If positive changes in clinical practice are found, this evidence will support health service adoption of implementation strategies to support improved antenatal care for this recognised risk to the health and wellbeing of the mother and child.

Trial registrations

Australian and New Zealand Clinical Trials Registry, No. ACTRN12617000882325 (date registered: 16/06/2017).

Women's perceptions of information about alcohol use during pregnancy: a qualitative study

Background

A number of alcohol guidelines worldwide suggest that pregnant women should abstain from alcohol. However, high prevalence rates of alcohol consumption during pregnancy still exist. It is unknown whether there are problems with the dissemination of guideline information that is potentially contributing to such consumption. This qualitative study aimed to explore women’s perceptions of information they received about alcohol use during pregnancy after the introduction of abstinence guidelines.

Methods

Nineteen women from the Australian Longitudinal Study on Women’s Health (ALSWH) 1973–78 cohort that reported a pregnancy in 2009 were recruited for semi-structured telephone interviews. The interviews were conducted until data saturation was reached. Interviews were transcribed, then thematically analysed. ALSWH survey data was used to augment the findings. The main outcome measure was women’s perceptions of information received about alcohol use during pregnancy after the introduction of the 2009 Australian guidelines promoting abstinence during pregnancy.

Results

Women reported a number of problems with the information about alcohol use during pregnancy and with its dissemination. There were inconsistencies in the information about alcohol use during pregnancy and in the advice provided. Mixed messages and confusion about identifying a safe level of consumption had implications on women’s decisions to drink or abstain during pregnancy. Women expressed a need for a clear, consistent message to be provided to women as early as possible. They preferred that the message come from healthcare professionals or another reputable source.

Conclusions

To make an informed decision about alcohol use during pregnancy, women must first be provided with the latest evidence-based information. As this study found a number of limitations with information provision, it is suggested that a systematic approach be adopted by healthcare professionals, in line with best-practice guidelines, to ensure all women are made aware of the alcohol recommendations for pregnancy.