In recent years the month of January has been labelled Dry January in attempt to encourage people to have a break from alcohol. But what about pregnant women and what are the effects of the consumption of alcohol on the unborn baby? In this article researchers, Dr Lisa Schölin and Professor Lesley Smith, discuss the current evidence and challenges around use of alcohol in pregnancy
Preventing alcohol-related harm in 2022 – how research is informing practice and policy to better support pregnant women and their children
Dr Lisa Schölin[1] and Professor Lesley Smith[2]
As the new year began, many people will have adopted the ‘new year, new me’ approach, giving up alcohol for the duration of January. For some, this may be more challenging than for others, which can also be the case for pregnant women. The potential harmful effects of alcohol consumption during pregnancy started to emerge during the late 1960s and early 1970s, when Fetal Alcohol Syndrome was first described. Since then, this field of research has developed from initially taking a primarily biomedical focus to now include a broader multi-disciplinary research base.
Despite now several decades of attention to this important issue, we reflect on some of the central areas of focus in the UK in 2022.
Fetal Alcohol Spectrum Disorder (FASD) prevalence research in the UK
Regardless of decades of research internationally, a key issue that has plagued the field in the UK is the lack of robust data on the prevalence of FASD; that is the number of individuals in the population with FASD. In 2019-20 the first UK study to use an active case ascertainment method to estimate the prevalence of FASD was carried out. It involved 220 children in schools aged 8–9 years in Greater Manchester. From the child assessments 1.8% were diagnosed with FASD; 3.6% identified as children with possible FASD were also included (cases where FASD was suspected but information about, for example, alcohol exposure was missing). This prevalence is likely to be a conservative estimate due to the profile of the children who were absent from school on the assessment days. It is broadly in line with a large meta-analysis of global data which estimated prevalence for the UK as approximately 3%. Another study which applied a screening algorithm to data collected in the long term ALSPAC study, which involved women who were pregnant in the early 1990s and lived in the Bristol area, suggested that 6–17% of the children born to women in the cohort could have FASD.
Strong evidence on how common FASD is in the UK is still needed to increase the precision of these estimates. We have previously highlighted the issue around the much-needed funding of research studies in the UK, which to date has been limited and a challenge for researchers to obtain.
Understanding alcohol consumption during pregnancy
Why do some pregnant women drink alcohol? A recent review of international studies that explored the reasons why women consume alcohol during pregnancy found that individual beliefs, cultural importance of consuming alcohol in social contexts, lack of awareness of negative outcomes (such as FASD) were factors that influenced women’s drinking behaviours when pregnant. The most common reasons were societal pressure and beliefs that only large amounts or specific types of alcohol were harmful. While some reasons were more evident in countries with “greater sense of tradition and collectivist culture (e.g. Ghana, India, Bhutan)”, beliefs about risk thresholds came across in studies from many different countries. This suggests that the idea that some alcohol might be okay persists across the world, which can be challenging when having conversations with women in antenatal care.
Helping midwives to support women
Our research has recently also focused on the role of midwives, who are a key source of advice and support to women during pregnancy, and how antenatal care can be an opportunity to discuss alcohol with women in a sensitive and supportive way. Our large survey of UK midwives (Midwives’ Assessment of expecting Mothers’ Alcohol use; MAMA) indicated that some of the main barriers to addressing alcohol with women during antenatal appointments included that they were unsure about the exact content of the guidelines and what advice to give; that they lacked sufficient communication skills and confidence to discuss alcohol consumption and associated harms with women; and were worried about offending or upsetting women by addressing the topic. In our qualitative study, midwives told us that changes to alcohol guidelines in recent years can make it confusing to advise women; for example, whether occasional drinking is harmful, which was permissible in the previous guidelines.
Our current study (AlCohol HArM PreventION in Pregnancy: CHAMPION) seeks to develop implementation strategies to support midwives addressing alcohol with women at each antenatal appointment. These strategies have been co-designed with midwives and maternity service users to directly address the barriers midwives face that we previously identified in the MAMA study and from a wider review of the literature. We will start pilot testing these strategies with midwives in Hull and Gateshead during early spring 2022.
Further prevention efforts are ongoing in Greater Manchester with the prevention of alcohol exposed pregnancies programme of work. Alcohol care pathways have been embedded into two NHS Trusts in the North West of England which has resulted in more women signposted to appropriate services. The #DRYMESTER campaign is also raising awareness of FASD across the region and nationally.
While the current state of play indicates that there is still some way to go before we have all of the answers to important research questions about prevention, diagnosis and treatment of alcohol-related harm during pregnancy, in the UK we are on a trajectory towards filling some of the gaps.
[1] Lisa Schölin is a postdoctoral research fellow at the Centre for Pesticide Suicide Prevention at University of Edinburgh. She has previously held research posts in alcohol policy at University of Stirling and University of Edinburgh and has worked in international alcohol policy at WHO Europe and the Foundation for Alcohol Research and Education. Most recently she has worked as a researcher for the Mental Welfare Commission for Scotland where she led monitoring and research projects around mental health and incapacity legislation.
[1] Lesley Smith is Professor in Women’s Public Health at University of Hull. Her research takes a life course approach by looking at opportunities for supporting behaviour change for harm and disease prevention. A focus is on women of reproductive age and prevention of alcohol-related harms during preconception and pregnancy. She currently leads the ‘AlCohol HArM PreventIOn iN pregnancy: CHAMPION’ project funded by the NIHR RfPB programme.