Fetal alcohol spectrum disorders: Current issues in awareness, prevention and intervention
How preventable is FASD?
The more a woman drinks during pregnancy, the higher the risk to the unborn child (Burns, Elliot et al., 2012). The relationship between alcohol consumption and the expression of FASD is complex; not all children who are exposed to high levels of alcohol during gestation will be affected to the same degree (O'Leary, 2004). A number of complex and interrelated factors influence the relationship between alcohol exposure and risk to the unborn child. These include the pattern and amount of alcohol consumption, the stage(s) of fetal development during which exposure occurred, and maternal factors unrelated to alcohol exposure such as genetics, socio-economic factors, age at conception and nutritional status (May & Gossage, 2011).
It is widely accepted that binge drinking behaviour (4-5 or more standard drinks per occasion) is one of the biggest risk factors for FASD (Flak et al., 2014; Maier & West, 2001; Paintner, Williams, & Burd, 2012). This is thought to be because binge drinking leads to a higher peak alcohol concentration. Alcohol crosses readily into the placenta and the fetus from the maternal bloodstream (Paintner et al., 2012) and is metabolised at a constant rate regardless of the amount consumed. Binge drinking episodes produce both higher blood alcohol concentrations and longer exposure than regular, lower level alcohol consumption does (Maier & West, 2001).
While there may be agreement about the harm caused by binge drinking, there is still significant debate around the acceptable safe lower limits for alcohol consumption, resulting in unclear messages regarding safe levels of alcohol consumption during pregnancy (O'Leary & Bower, 2012).
There is evidence that even low levels of alcohol exposure are related to observable changes in children's behaviour later in their development. A meta-analysis of the association between mild, moderate, heavy and binge drinking patterns noted that there was an association between drinking at levels of less than 1 drink per day (3 to 6 drinks per week) and behaviour concerns in children between 9 months and 5 years of age (Flak et al., 2014). Similarly, O'Leary and Bower (2012) found an increased risk of neurodevelopmental problems and of pre-term birth associated with the consumption of the equivalent of only 2-2.5 standard drinks once or twice per week.
What should practitioners advise women?
National Health and Medical Research Council (NHMRC) (2009) guidelines recognise the current ambiguous state of knowledge regarding low levels of alcohol consumption in pregnancy and state that:
A no-effect level has not been established, limitations in available evidence make it impossible to set a safe or not-risk level of drinking for women to avoid harm to their unborn children, although the risks to the fetus from low level drinking (such as one or two drinks per week) during pregnancy are likely to be low. A conservative public health approach has therefore been taken in recommending that "not drinking alcohol is the safest option" for pregnant women and women planning a pregnancy. (NHMRC, 2009, p. 68)
At present, while there is inconclusive evidence as to the impact of low levels of alcohol consumption during pregnancy, the safest choice is not to drink: the only known way to prevent FASD is to abstain from consuming alcohol during pregnancy. Prenatal alcohol exposure is the only cause of FASD and the leading cause of preventable brain damage (O'Leary, 2002).
Family counsellors, obstetricians and allied health practitioners in traditionally adult-focused services need to be aware of the potential impact of alcohol use on the developing child and ask about alcohol use during pregnancy. When asked, pregnant women reported positive experiences of discussing alcohol use and risk reduction with professionals (Jones, Telenta, Shorten, & Johnson, 2011). This suggests that the relationship between professionals and pregnant women need not be harmed by conversations about alcohol use.
For women who are pregnant or planning a pregnancy, not drinking is the safest option. (NHMRC, 2009, p. 78)
What are the factors that influence whether women consume alcohol during pregnancy?
Alcohol consumption is seen by many as an integral part of the fabric of Australian life (Department of Health and Ageing, 2001). The Australian Institute of Health and Welfare household survey of alcohol use (AIHW, 2011) suggests that 34% of Australian women consume alcohol weekly and 5% consume alcohol daily. In addition, binge drinking is highest among women aged 18-29, a group that are within childbearing age (AIHW, 2011; Burns, Elliot et al., 2012). The high rate of risky alcohol consumption among women of childbearing age is concerning as it is thought that around 45% of all pregnancies may be unplanned (Burns, Elliot et al., 2012; Colvin, Payne, Parsons, Kurinczuk, & Bower, 2007; Naimi, Lipscomb, Brewer, & Gilbert, 2003). A study of Australian women recently reported that around 30% of women with children now aged up to 5 years, retrospectively reported alcohol consumption during pregnancy (Hutchinson, Moore, Breen, Burns, & Mattick, 2013).
Research exploring the dynamics of alcohol consumption during pregnancy suggests groups of high-risk women who could be targeted through public health approaches. The following factors appear associated with greater alcohol consumption during pregnancy:
- pre-pregnancy and current rates of alcohol use (both higher quantity and frequency) (Skagerstrom et al., 2011; Zammit, Skouteris, Werthein, Paxton, & Milgrom, 2008);
- socio-economic advantage and family income: higher income tends to be associated with increased alcohol consumption pre-pregnancy and during pregnancy (Hutchinson, et al., 2013; Skagerstrom et al., 2011; Zammit et al., 2008);
- being an older woman with higher educational attainment (Hutchinson et al., 2013);
- smoking during pregnancy (Hutchinson et al., 2013);
- a history of abuse or exposure to violence (Skagerstrom et al., 2011).
In Australian research, intention to consume alcohol in pregnancy was associated with alcohol use in past pregnancy, the belief that pregnant women should be able to drink alcohol, intention to smoke during pregnancy, and holding a neutral or positive attitude towards alcohol use during pregnancy (Peadon et al., 2010; Peadon et al., 2011). While around one-third of women indicated that they would continue to consume alcohol if they were planning a pregnancy, over one-third also indicated they would be less likely to drink if their partner stopped drinking, or encouraged them to reduce or cease their drinking. This suggests the benefit of involving partners in interventions aimed at reducing prenatal alcohol exposure (Burns, Elliot et al., 2012).
Providing information about FASD alone is unlikely to be sufficient to change behavioural intentions with respect to future alcohol consumption during pregnancy (Burns, Elliot et al., 2012). Multiple strategies, including engaging with partners and addressing societal and community views towards alcohol consumption may be necessary (FARE, 2013).
What factors influence whether women seek help?
The accessibility and effectiveness of treatment services for substance-abusing pregnant women needs to be improved (Burns, Woods, & Breen, 2012) as there is some evidence that only 10-50% of women who fall into this category will actually access treatment (Hankin, McCaul, & Heussner, 2000). There are various reasons why women may not seek help. There may be high levels of shame or stigma associated with help seeking and practitioners need to guard against conveying blame towards women who seek support (Burns & Breen, 2013; NoFASD, n. d.; Russell Family Fetal Alcohol Disorders Association [RFFADA], 2014). Women may feel anxious about accessing treatment and support services, when available, due to fears of involving child welfare services. Practical concerns, such as a lack of transportation and childcare or services not prioritising the needs of pregnant women, may also act as deterrents (Burns & Breen, 2013; Greenfield et al., 2007).
The quality of a woman's relationship with her partner may also influence whether or not she seeks out and remains in treatment. Among the factors that influence help seeking are the partner's attitude to alcohol consumption and treatment and the presence of abuse during pregnancy (Burns, Woods et al., 2012; Messer et al., 1996) Those with a partner who also uses alcohol and/or those experiencing sexual or physical abuse during pregnancy were also more likely to accept an offer of treatment (Messer et al., 1996).
What services might be helpful for pregnant women who are drinking?
At this stage, there does not yet appear to be enough high quality information about the relative effectiveness of psychological and pharmacological interventions to support affected women (Burns, Woods et al., 2012). In the absence of good evidence for effective intervention, screening for alcohol consumption remains an important step. At present, there is no systematic approach to screening women for at-risk alcohol consumption in Australia. The potential for using a standard questionnaire to facilitate early detection of women at risk has been explored (Nilsen, 2009; Johnson et al., 2011. The Western Australian model of care recommends using the AUDIT-C protocol for the screening of women of childbearing age (Department of Health, Western Australia, 2010). The AUDIT-C is a series of brief screening questions that provides a measure of risk in relation to alcohol consumption in pregnancy.
For women who are considered low-risk drinkers, education and monitoring may be sufficient, whereas risk assessment and engaging clients in behavioural contracts related to drinking (see Neale, 1991) may be advisable for those at moderate risk (Burns, Woods, & Breen, 2012). High-risk and/or alcohol-dependant women may require inpatient admission and supervision (Burns, Woods et al., 2012).
Integrated treatment programs may be effective in reducing substance use. In these programs, substance-use treatment is incorporated with pregnancy, parenting or child-focused services. Adult- focused service providers, such as drug and alcohol counsellors, should ask about the possibility of pregnancy among their clients. Other potentially effective supports may include outpatient therapy, group therapy, couples therapy and self-help groups (Burns, Woods et al., 2012), active and extended case management and referrals and support across a range of services including medical, transportation, mental health, vocational and legal support (Lester, Andreozzi, & Appiah, 2004).