Nineteen women (19% of those approached) were interviewed. An additional two women mailed back signed consent forms, but were unable to be contacted for interviews after multiple attempts. None of the 81 non-participants (81% of those approached) explicitly opted out of the study by actively declining participation. Interviews lasted an average of 46 minutes, ranging from 20 to 78 minutes.
Socio-demographic and health behaviour characteristics for participants are included in Table 2. Participants were aged 31–36 years (M = 33.73, SD = 1.77) when pregnant in 2009. At the 2009 survey, around half of the women were from major cities, worked full time and had a university degree. During their 2009 pregnancies, 42% of the women were pregnant with their first child, whereas the remaining 58% already had at least one child. Most women altered their drinking behaviour from before pregnancy to during pregnancy. Twelve women reported drinking alcohol during pregnancy (63%) and seven abstained (37%). Of the twelve women who consumed alcohol during pregnancy, the majority (67%) drank less than once a week and none of them usually drank more than 1 or 2 drinks on a drinking day.
A faulty information delivery system
It was apparent from the outset of the analysis that no consistent message about alcohol use was systematically provided to pregnant women. On the contrary, there were multiple messages from a number of different information sources. This overarching theme encompassed a number of subthemes describing faults in the information pool and pathways. Differences were seen between the amount of information obtained, the recommendations about alcohol use during pregnancy, and the interpretation of the recommendations.
Information overload versus no information
Most of the women described the amount of overall information provided during pregnancy as overwhelming, particularly with their first child. Being overwhelmed had consequences for women’s ability to process the information, as one woman mentioned, ‘I disregarded a lot of the advice because I felt overwhelmed’ (Participant 11). The women were given a range of information (e.g. healthcare choices, healthy lifestyle factors) by a number of sources, such as books, media, formal education, healthcare providers, family, friends, websites, and antenatal classes. Those who found conflicting information between sources, would sometimes create a hierarchy, often relying on healthcare providers to explain the discrepancies and as one woman mentioned, to ‘just steer me in the right direction’ (Participant 15).
Not all women were overwhelmed, with one woman feeling more comfortable with the more information she got. Other women described a lack of information, particularly on lifestyle factors such as alcohol use. Self-sourcing information in the absence of it being provided was common, as one woman put it, ‘GP gave me nothing, obstetrician gave me nothing… it's all about the pregnant me sourcing it’ (Participant 5).
Women differed in the amount of information they received about alcohol use during pregnancy, with some getting recommendations from a number of sources and others not getting told anything. Some women were provided with information by healthcare providers, but generally not prior to or at pregnancy confirmation, but rather weeks later at their first antenatal appointment closer to their second trimester. Those who were not advised by a healthcare provider believed it was because they were non-drinkers or did not ‘look like someone that would be swigging away at some alcohol every night’ (Participant 6). Many women did not receive as much information in subsequent pregnancies compared with their first. Not receiving information had implications for how they then made their decisions about whether or not to drink during pregnancy:
I don't remember getting any formal information, but I think I just had in my head that, you know, healthy lifestyle is important, so I sort of ate well and sort of didn't have three or four drinks if I went out for dinner or something. I'd only have one or two, sort of take a bit more care of my health. I couldn't say where I got the reasoning for that. I think that's just a build-up of information over my lifetime sort of thing. (Participant 9)
It’s [alcohol advice for pregnancy] not promoted anywhere. To me, that’s a bit of a concern for me, that women perhaps just aren’t getting the advice. At least, if… you’ve got the advice and you’ve got the information, you can make the decision. (Participant 10)
What is the recommendation anyways? Depends who you ask
It was common knowledge that heavy alcohol use was not recommended during pregnancy, and that alcohol should be avoided during the first trimester. However, there were discrepancies in the recommendation that women received about a safe level of consumption, varying from abstinence to light consumption:
I have this really vivid image of, during my first pregnancy,… [the GP] saying that it’s now recommended that you don’t have any alcohol… in the second one I’m sure that was reiterated. (Participant 16)
He [my obstetrician] did say that it's not ideal, but the odd glass here and there wouldn't hurt. (Participant 17)
Some women were aware that recommendations had changed over time, believing this reduced the strength of the message. When faced with this inconsistency, women sometimes relied on personal experience or the experience of others to determine which message they chose to believe:
They'll say small amounts of alcohol are okay. Then we go back to saying no alcohol during the pregnancy. Women kind of think well hang on, I've got lots of friends that did drink small amounts of alcohol during their pregnancy and their kids seem fine. So they don't place as much importance on that. (Participant 4)
Other messages regarding alcohol in general or other pregnancy issues often clouded the message about alcohol use in pregnancy. Some women heard alcohol, particularly wine, was beneficial because it contained antioxidants, promoted better sleep, and reduced stress. One participant believed stress was more hazardous during pregnancy than drinking alcohol, so she thought it was fine to have a glass of wine occasionally. Alternatively, another woman could not see any benefits in consuming alcohol during pregnancy.
Interpreting a grey area: ‘no safe level’ versus ‘no harm shown’
A number of women discussed how information defining a safe level of alcohol use was mixed. Some women expressed confusion or frustration about this, with one woman stating, ‘I just can’t see why there is that grey area’ (Participant 3). She could not understand why the information was unclear because there was no reported benefit of drinking during pregnancy. Another woman believed a grey area meant the evidence was not strong enough to support a recommendation of abstinence:
If it was that it was absolutely detrimental and more than one glass could kill the baby… and you had scientific evidence to back that up, well then that's the message that should be communicated… But I think it's such a grey area. (Participant 17)
Some of the women with science or health backgrounds understood the evidence for a safe level of consumption is inconclusive. This grey area led to two main interpretations. A number of women believed in a better safe than sorry approach, such as ‘If you don't know what the result is, don't do it. It's as simple as that’ (Participant 2). Whereas, other women had a relaxed approach, reflected by one woman saying, ‘There is no research to suggest that a couple of drinks is okay or not… to me that means that it's okay to have one or two now and then’ (Participant 7).
Improving the information delivery system
It became apparent during interviews that women had opinions on how to address faults in the information delivery system. This second overarching theme was therefore derived through further exploration of the first theme. Women believed a clear, consistent message needed to be delivered early on by a reliable source, as described in the three following subthemes.
Clear, consistent, and strong recommendation
Women believed the recommendation needed to remain consistent over time and be clearly delivered. Women who thought the recommendation should be abstinence and those thinking it should be low alcohol intake both believed that one message should be chosen and continued:
Stick with that message and keep that message going for years, not just, okay, this week it's that message and next week it's another. I think that's where people lose face… I think being consistent is really the only way to continually get a message across. (Participant 8)
One woman did not think a single message was possible, believing recommendations should be based on the individual. Although other women believed individual differences were relevant, they still thought a clear message was needed. One reason for this was to avoid individual interpretations, such as if the message was abstinence then some women might decide one drink was safe, but if it was one drink was okay then they may decide two drinks was alright. A straightforward message of abstinence was suggested as a way of dealing with individual differences.
A number of women believed the message needed to be strong, with some suggesting scare tactics to make it more tangible. Women educated about Fetal Alcohol Spectrum Disorders thought visual depictions of children affected with these disorders could shock women into abstaining. Other women believed scaring pregnant women could cause undue stress, which could be harmful for the woman and fetus. Generally women thought the message would have more impact if reasons for the message were included:
People need to be made aware of the effects of drinking alcohol during pregnancy… People aren't just going to take it on face value. They need to know, well what's going to happen if I do have it. (Participant 4)
A reliable source with a vast reach
The strength of the message was also thought to be influenced by the source of information. Women viewed healthcare providers as reliable sources with expert knowledge. A hierarchy among healthcare providers was described, but this varied depending on the type of care received. A number of women thought doctors, primarily obstetricians, were more knowledgeable then nurses and midwives, but other women thought midwives knew more than doctors. Despite these discrepancies, most women believed the alcohol message should be provided by healthcare providers:
The only cohesive factor in all that is the person that's giving you the [health]care while you're pregnant. Because not all women will read books, not all women have access to the internet… or use the internet. (Participant 5)
Additionally, women mentioned a need to utilise sources such as television, printed media, social media and websites to raise awareness of the current recommendations, since they have changed over time. Such an approach was said to help ‘get rid of that old thinking’ (Participant 9) from previous pregnancies, which may be outdated. Some women expressed a need to target certain groups to ensure all women within Australian society are aware of the alcohol recommendations for pregnant women. One woman said information needed to be provided ‘in a lot of different locations that people of all classes can access’ (Participant 15). Regardless of how they thought the message should be delivered, women believed it should come from a reputable source to have an impact. In addition to healthcare providers and healthcare bodies, the government and universities were considered valid sources for passing on alcohol recommendations to pregnant women.
Early information provision
Women believed advice about alcohol recommendations should be provided before the first antenatal appointment, which was often late in the first trimester or the beginning of the second trimester. They were aware that the first trimester is a crucial time for development, so information was wanted early:
Your first 12 weeks, as you know, it's the most critical… so you want to get it[information]… before that time. It's a bit late when you go to your doctor for your eight week, 10 week scan. (Participant 2)
Women suggested information be provided when planning a pregnancy or at the GP when getting a pregnancy confirmed. The women acknowledged that not all pregnancies are planned, so they considered the GP visit for pregnancy confirmation a critical teachable moment:
That's [the GP visit for pregnancy confirmation] when you're taking in the most information… You're trying to learn everything. I think that's where you need to really nail it and get the message across. (Participant 6)
Some women thought information about alcohol use in pregnancy should be part of education in schools. The women thought it may deter students from having unprotected sex while drinking alcohol, as well as making it common knowledge from a young age.