Drinking alcohol in pregnancy can harm the unborn child and may cause a range of neurodevelopmental disorders including Fetal Alcohol Spectrum Disorder (FASD).1
This report is a part of the Evidence-practice policy gap (EPPG) publication for Aboriginal and Torres Strait Islander health.
What is the gap and why is it important?
FASD is a diagnosis that can result from prenatal alcohol exposure. According to the 2016 Australian Guide to the Diagnosis of FASD, it is categorised as either FASD with three sentinel facial features (previously referred to as Fetal alcohol syndrome [FAS]) or FASD with fewer than three sentinel facial features.2 FASD is characterised by lifelong intellectual disability, behavioural and developmental impairment, and is also potentially preventable. It is estimated that approximately 60% of Australian pregnancies are alcohol-exposed.3, 4 Although a smaller percentage of Indigenous Australian women drink alcohol compared with non-Indigenous Australian women, they tend to drink at high-risk levels.5 In 2014–2015 the National Aboriginal and Torres Strait Islander Social Survey 2014-15 found that approximately 10% of Indigenous Australian children aged 0–3 years-old had prenatal alcohol exposure, which is about half the rate found in 2008. Most of this difference was due to decreases in non-remote areas. In 2010/2011 in the remote Fitzroy Valley, Western Australia (WA), 55% of women who participated in a population based study reported alcohol use during pregnancy (for children born in 2002/2003), and 95% of these women drank at risky to high-risk levels.6 Their children had among the highest rates (19%) of FASD worldwide.7 To maximise opportunities for prevention and identification of children at risk for FASD, all women should be educated about the potential harms of alcohol use in pregnancy. The World Health Organisation recommends that all women who are pregnant or planning a pregnancy should be asked and advised about alcohol consumption at every antenatal visit, and be referred to treatment and support services as necessary.8
Health professionals are well-positioned to prevent FASD through providing accurate and timely advice about risks, complications and referral services, however gaps exist in their knowledge, skills and confidence. Although 98% of health professionals in Western Australia provide advice consistent with NHMRC guidelines on alcohol use during pregnancy (see NHMRC's alcohol guidelines),9 some pregnant women receive inaccurate advice,10 and opportunities for prevention and diagnosis are missed. For example, only 46% of health professionals routinely ask pregnant women about alcohol use and 32% inform them about the consequences.11 In addition 70% of mothers of children with FAS do not have an alcohol-related diagnosis recorded during pregnancy, and 51% of children with FAS already have an affected sibling.12, 13 Most health professionals are unaware of the availability of high-quality, culturally appropriate FASD prevention resources.
What does the best available evidence tell us?
Abstinence from alcohol during pregnancy prevents FASD,2 however evidence on effective prevention approaches for FASD is of poor quality, so it is not possible to recommend one particular approach for sustained and effective behaviour change in pregnant women.14, 15 Nevertheless, 97-99% of Australian women expect health professionals to ask, advise, and readily provide information to them about potential harms from alcohol use in pregnancy.11 Specifically, advice was sought from antenatal services by 54% of Indigenous mothers who reported alcohol use during pregnancy (see Aboriginal and Torres Strait Islander Health Performance Framework). Prenatal screening followed by empathetic interventions by health professionals has been shown to be effective in reducing prenatal alcohol exposure in USA. Research in 2015 with American Indian/Alaska Native women, showed that assessment of maternal alcohol use alone, even without intervention, reduced vulnerability to prenatal alcohol exposure.16 Asking and advising women about alcohol use is a logical first step to enabling the identification of women with alcohol use and misuse and children at risk for FASD.2 Starting the conversation with all pregnant women provides the health professionals an opportunity to offer advice on alcohol use, brief intervention, referral, and monitoring. Contraception is an important component of prevention for women of child-bearing age who regularly drink alcohol.
The reasons for harmful alcohol consumption by Aboriginal people are complex and must be understood in the context of whole-of-life experience including historical trauma, cultural, and economic circumstances.17 Health professionals should provide a culturally safe service, informed by Aboriginal Health Workers, and preferably delivered with Indigenous practitioners (see UNSW).
What is the current practice or policy?
National guidelines recommend that health professionals : i) ask all pregnant women about alcohol consumption using a standardised tool (the Alcohol Use Disorders Identification Test-Consumption [AUDIT-C]);2 ii) advise that not drinking is the safest option; iii) provide brief intervention to women who drink during pregnancy; and iv) refer to specialist medical services if necessary.8, 18, 19 Only 64% of midwives provide pregnant women with information about harms of prenatal alcohol exposure, and 70% provide brief interventions when indicated.20 Only 22% of paediatricians ask about alcohol use and 10% provide information about prenatal alcohol exposure.21 In Hunter New England Health, 64% of women surveyed were not asked about alcohol use and only 35% received appropriate advice and referral.22 The AUDIT-C, treatment advice and referral pathways have now been embedded in their e-maternity system (NHMRC Partnership grant #1113032). Additional Australian Government-funded initiatives include the National FASD Action Plan (2014) and the National FASD Strategic Action Plan (2018-2028).
What would the impact be if the proposed action was implemented?
If all women who were pregnant or planning a pregnancy were asked about alcohol use by their health professionals, advised that no alcohol is the safest option and provided with support to abstain from alcohol throughout pregnancy or obtain treatment for alcohol misuse or dependency, the expected impact would be:
- A reduction in the numbers of alcohol-related adverse pregnancy, neonatal and child health outcomes
- Increased awareness and a systematic approach to supporting women who consume alcohol
- Early follow-up of children prenatally exposed to alcohol and earlier identification of FASD
- Harm prevention through education of patients, and earlier support for mothers at risk of drinking alcohol in subsequent pregnancies
- A reduction in the numbers of FASD cases, and
- Acquisition of more accurate prevalence data on alcohol use in pregnancy to inform future services and interventions and monitor progress with prevention.
Prevention of alcohol use in pregnancy remains a challenge and will require legislative and societal attitudinal change and education to underpin behavioural change.23 The responsibility to prevent prenatal alcohol exposure and FASD should be shared amongst women, their partners, families/communities, health professionals and social services, society (with social norms not promoting risky drinking), and government.24
References
1 Lange, S., C. Probst, G. Gmel, J. Rehm, L. Burd, and S. Popova, Global prevalence of fetal alcohol spectrum disorder among children and youth: A systematic review and meta-analysis. JAMA Pediatrics, 2017: p. doi:10.1001/jamapediatrics.2017.1919.
2Bower, C., E.J. Elliott, and on behalf of the Steering Group, Report to the Australian Government Department of Health: "Australian Guide to the diagnosis of Fetal Alcohol Spectrum Disorder (FASD)". 2016, Australian Government Department of Health: Australia.
3 Muggli, E., C. O'Leary, S. Donath, F. Orsini, D. Forster, P.J. Anderson, S. Lewis, C. Nagle, J.M. Craig, E. Elliott, and J. Halliday, "Did you ever drink more?" A detailed description of pregnant women's drinking patterns. BMC Public Health, 2016. 16: p. 683.
4McCormack, C., D. Hutchinson, L. Burns, J. Wilson, E. Elliott, S. Allsop, J. Najman, S. Jacobs, L. Rossen, C. Olsson, and R. Mattick, Prenatal alcohol consumption between conception and recognition of pregnancy. Alcohol Clin Exp Res, 2017. 41(2): p. 369-378.
5 Australia. Parliament. House of Representatives. Standing Committee on Indigenous Affairs, Alcohol, hurting people and harming communities: inquiry into the harmful use of alcohol in Aboriginal and Torres Strait Islander communities / House of Representatives, Standing Committee on Indigenous Affairs. Parliamentary paper (Australia. Parliament) ; 2015, no. 200., ed. S.N. Stone. 2015, Canberra: Standing Committee on Indigenous Affairs.
6 Fitzpatrick, J.P., J. Latimer, M.L. Ferreira, M. Carter, J. Oscar, A.L. Martiniuk, R.E. Watkins, and E.J. Elliott, Prevalence and patterns of alcohol use in pregnancy in remote Western Australian communities: The Lililwan Project. Drug Alcohol Rev, 2015. 34(3): p. 329-339.
7 Fitzpatrick, J.P., J. Latimer, H. Carmichael Olson, M. Carter, J. Oscar, B.R. Lucas, R. Doney, C. Salter, J. Try, G. Hawkes, E. Fitzpatrick, M. Hand, R.E. Watkins, T.W. Tsang, C. Bower, M.L. Ferreira, J. Boulton, and E.J. Elliott, Prevalence and profile of neurodevelopment and fetal alcohol spectrum disorder (FASD) amongst Australian Aboriginal children living in remote communities. Res Dev Disabil, 2017. 65(2017): p. 114-126.
8 World Health Organization, Guidelines for identification and management of substance use and substance use disorders in pregnancy. 2014, Switzerland: WHO Document Production Services.
9 Payne, J., K. France, N. Henley, H. D'Antoine, A. Bartu, C. O'Leary, E. Elliott, and C. Bower, Changes in health professionals' knowledge, attitudes and practice following provision of educational resources about prevention of prenatal alcohol exposure and fetal alcohol spectrum disorder. Paediatr Perinat Epidemiol, 2011. 25(4): p. 316-27.
10 Crawford-Williams, F., M. Steen, A. Esterman, A. Fielder, and A. Mikocka-Walus, "My midwife said that having a glass of red wine was actually better for the baby": a focus group study of women and their partner's knowledge and experiences relating to alcohol consumption in pregnancy. BMC Pregnancy Childbirth, 2015. 15: p. 79.
11 Payne, J.M., K.E. France, N. Henley, H.A. D'Antoine, A.E. Bartu, C.M. O'Leary, E.J. Elliott, C. Bower, and E. Geelhoed, RE-AIM evaluation of the Alcohol and Pregnancy Project: educational resources to inform health professionals about prenatal alcohol exposure and fetal alcohol spectrum disorder. Eval Health Prof, 2011. 34(1): p. 57-80.
12 Elliott, E., J. Payne, A. Morris, E. Haan, and C. Bower, Fetal alcohol syndrome: a prospective national surveillance study. Arch Dis Child, 2008. 93(9): p. 732-737.
13 O'Leary, C.M., J. Halliday, A. Bartu, H. D'Antoine, and C. Bower, Alcohol-use disorders during and within one year of pregnancy: a population-based cohort study 1985-2006. BJOG 2013. 120(6): p. 744-53.
14 Ospina, M., C. Moga, L. Dennett, and C. Harstall, A systematic review of the effectiveness of prevention approaches for Fetal Alcohol Spectrum Disorder, in Prevention of Fetal Alcohol Spectrum Disorder FASD. 2011, Wiley-VCH Verlag GmbH & Co. KGaA. p. 99-335.
15 Symons, M., R.A. Pedruzzi, K. Bruce, and E. Milne, A systematic review of prevention interventions to reduce prenatal alcohol exposure and fetal alcohol spectrum disorder in indigenous communities. BMC public health, 2018. 18(1): p. 1227.
16 Montag, A.C., S.K. Brodine, J.E. Alcaraz, J.D. Clapp, M.A. Allison, D.J. Calac, A.D. Hull, J.R. Gorman, K.L. Jones, and C.D. Chambers, Preventing alcohol-exposed pregnancy among an American Indian/Alaska Native population: effect of a screening, brief intervention, and referral to treatment intervention. Alcoholism, clinical and experimental research, 2015. 39(1): p. 126-35.
17 Hayes, L., H. D'Antoine, and M. Carter, Addressing fetal alcohol spectrum disorder in Aboriginal communities, in Working Together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice, P. Dudgeon, H. Milroy, and R. Walker, Editors. 2014, Department of the Prime Minister and Cabinet, Australia: Perth. p. 355-71.
18 National Health and Medical Research Council, Australian Guidelines to Reduce Health Risks from Drinking Alcohol. 2009, Commonwealth of Australia: Canberra.
19 National Drug & Alcohol Research Centre, Supporting pregnant women who use alcohol or other drugs: A guide for primary health care professionals. University of New South Wales.
20 Payne, J.M., R.E. Watkins, H.M. Jones, T. Reibel, R. Mutch, A. Wilkins, J. Whitlock, and C. Bower, Midwives' knowledge, attitudes and practice about alcohol exposure and the risk of fetal alcohol spectrum disorder. BMC Pregnancy Childbirth, 2014. 14: p. 377.
21 Payne, J., K. France, N. Henley, H. D'Antoine, A. Bartu, R. Mutch, E. Elliott, and C. Bower, Paediatricians' knowledge, attitudes and practice following provision of educational resources about prevention of prenatal alcohol exposure and fetal alcohol spectrum disorder. J Paediatr Child Health, 2011. 47(10): p. 704-710.
22 Doherty, E., J. Wiggers, L. Wolfenden, A.E. Anderson, K. Crooks, T.W. Tsang, E.J. Elliott, A.J. Dunlop, J. Attia, J. Dray, B. Tully, N. Bennett, H. Murray, C. Azzopardi, and M. Kingsland, Antenatal care for alcohol consumption during pregnancy: pregnant women’s reported receipt of care and associated characteristics. BMC Pregnancy Childbirth, 2019. 19(1): p. 299.
23 Tsang, T.W. and E.J. Elliott, High global prevalence of alcohol use during pregnancy and fetal alcohol syndrome indicates need for urgent action. Lancet Glob Health, 2017. 5(3): p. e232-e233.
24 Jonsson, E., A. Salmon, and K.R. Warren, The international charter on prevention of fetal alcohol spectrum disorder. Lancet Glob Health, 2014. 2(3): p. e135-e137.
