September 8, 2017
There is a clear causal link between heavy consumption of alcohol and FASD. However, the link between low-level alcohol exposure and the risk of harm to children developing in the womb is yet to be properly understood. This uncertainty has led to mixed messages and some confusion.
Negative research findings reported in some media outlets has led to further confusion.
Articles such as ‘Telling pregnant women to drink no alcohol is counterproductive’ raise important questions about challenging social and cultural accepted ‘norms’, underestimating the potential adverse outcomes, and complicate decision-making about the risks versus benefits of light–moderate drinking during pregnancy1.
FASD appears more likely to be prevalent in at-risk communities, children in contact with youth justice services are thought to include an over-representation of individuals living with undiagnosed FASD2 3.
But more information about the prevalence and nature of FASD is required to allow for improved interventions, early detection and service planning and implementation. Prioritising prevention and providing adequate screening and diagnostic tools to ensure early intervention for those children with pre-existing FASD 4 is required – particularly with identified at-risk communities.
Australia’s response to FASD has been slower to develop than many other countries; it’s only since May 2016 that a clear diagnostic criteria has been formalised.
The outcomes of a formal inquiry into FASD published in 2012 set out a list of 19 key recommendations to begin addressing the harms associated with prenatal alcohol exposure, the consequences of FASD, and the economic and social impact of the condition5.
The development of a national approach in three key areas, prevention, intervention and management, was identified with particular reference to education, diagnostic tools and improved access to support services.
The 2016 adoption of the formal diagnostic criteria is a positive outcome in relation to intervention and management3.
Australian guidelines set out by the NHMRC:
‘For women who are pregnant or planning a pregnancy, not drinking is the safest option’.
It is difficult to determine the minimum dose that will affect the developing baby and the exact dose-response relationship. A ‘no-effect’ level has not been established and limitations in the current evidence make it difficult to set a ‘safe’ or ‘no-risk’ drinking level for women in order to avoid harm. However, the risk of harm from low-level drinking (such as drinking before knowing she was pregnant) is likely to be low26.
Regular drinking (four or more standard drinks in one sitting, at least once-per-week) or binge drinking (more than five drinks in one sitting) particularly in the first trimester of pregnancy, is strongly associated with FASD-related characteristics3.
Recent meta-analysis observed that prenatal exposure at less than daily drinking might be associated with detrimental child behaviour, and provided evidence that there is no known safe amount of alcohol to consume when pregnant6.
Alcohol use in society is often dependent on a range of individual, social and cultural factors.
Alcohol use during pregnancy may be driven by the influence of these factors; and could reflect attitudes towards alcohol in the general Australian society where its consumption is socially acceptable and highly prevalent. Data from the 2016 National Drug Strategy Household Survey showed that 78% of Australians over the age of 14 years had consumed alcohol in the past year, 5.9% drank on a daily basis and 17.1% consumed more than two standard drinks per day7. Women continuing to drink during pregnancy may partly be attributed to a drinking culture 8.
Awareness of FASD must: “engage women, men and families; be culturally sensitive; be informed by community knowledge, attitudes, values and drinking practices; and to be consistent with national guidelines”9.
Stigma and judgement remain significant barriers to both diagnosis/reporting and information provision during pregnancy.
The notion of blame can shape attitudes towards and reactions to women who drink during their pregnancy.
‘Blame and shame’ can negatively impact the self-perception of pregnant women; with many women fearing they will be negatively judged by the general public and health care workers if they disclose the full extent of their alcohol consumption11.
This potential negative judgement may further prevent early monitoring and support for women, and delay diagnosis and effective early interventions for the child11.
It’s important to recognise that decisions about alcohol-use during pregnancy occurs within the context of the broader home and social environment. Australian data reports that 75% of pregnant women are most likely to drink in their own home with their partner, with the partner initiating the drinking occasion in 40% of occasions10.
This means that prevention policy development requires well-designed planning that targets the community, not just women.