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Pregnant women’s understanding and conceptualisations of the harms from drinking alcohol: a qualitative study

Background Despite women’s awareness that drinking alcohol in pregnancy can lead to lifelong disabilities in a child, it appears that an awareness alone does not discourage some pregnant women from drinking. Objectives To explore influences on pregnant women’s decision making around alcohol use in a population with frequent and heavy peer drinking (i.e. in two Indigenous Australian communities) and another of non-Indigenous pregnant women attending antenatal care in a range of socioeconomic settings. Methods Individual and group discussions were held with both Indigenous Australian and non-Indigenous pregnant women attending a variety of antenatal care models, including two Indigenous maternity services in Australia. Data were analysed using inductive content analysis. Results A total of 14 Indigenous Australian and 14 non-Indigenous pregnant women participated in this study. Analysis identified five main influences on pregnant women’s alcohol use: the level and detail of women’s understanding of harm; women’s information sources on alcohol use in pregnancy; how this information influenced their choices; how women conceptualised their pregnancy; and whether the social and cultural environment supported abstinence. Conclusions for practice This study provides insight into how Indigenous Australian and non-Indigenous pregnant women understand and conceptualise the harms from drinking alcohol, including how their social and cultural environments impact their ability to abstain. Strategies for behaviour change need to: correct misinformation about supposed ‘safe’ timing, quantity and types of alcohol; develop a more accurate perception of Fetal Alcohol Spectrum Disorder; reframe messages about harm to messages about optimising the child’s health and cognitive outcomes; and develop a holistic approach encompassing women’s social and cultural context.


Introduction
Current research suggests that alcohol use in pregnancy continues to be prevalent despite antenatal 45 guidelines advising against drinking. The 2009 Australian National Guidelines to Reduce Health 46 Risks from Drinking Alcohol recommend that it is safest for women to abstain from drinking 47 alcohol completely throughout the duration of their pregnancy [1]. However, data from two large 48 national surveys of Australian women aged 18 to 45 years found that 34 to 49% of women 49 consumed alcohol in pregnancy [2,3], and that despite women's awareness that drinking alcohol in 50 pregnancy can lead to lifelong disabilities in a child, nearly one third intended to drink alcohol in a 51 future pregnancy [2]. Whilst knowledge of the potential harms of alcohol consumption during 52 pregnancy is important, it is apparent that an awareness alone does not discourage some women 53 from drinking when pregnant. The relatively high prevalence of alcohol consumption during 54 pregnancy has also been reported in other high-income countries. An international cross-cohort 55 comparison of the prevalence of alcohol use during pregnancy revealed that high rates of alcohol 56 consumption in pregnancy, between 20 and 80%, were evident despite knowledge of the guidelines 57 recommending abstinence [4]. Of additional concern are the levels of alcohol consumed in some 58 sub-populations. For example, an Australian survey reported that of the 55% of Indigenous 59 Australian women who consumed alcohol in pregnancy, nearly half drank at least two to three times 60 per week and almost all consumed a minimum of seven standard drinks per occasion [5]. Similarly, 61 a 2017 systematic review found that around one in five Indigenous women in North America drink 62 at binge levels when pregnant [6]. 63 While it is generally understood that frequent and heavy drinking among peers in populations with a 64 low socioeconomic background is strongly associated with frequent and heavy alcohol use in 65 pregnancy, [7] women who were highly educated, and/or with high incomes are also well 66 represented among those who continue to drink in pregnancy, albeit at lower levels of consumption risk perception rather than the advice from guidelines and health professionals. It appears that a 70 single health message to abstain from alcohol in pregnancy is not effective, especially in this 71 population. Advice for pregnant women may need to be tailored to allow for social influences, 72 attitudes, and personal experience, depending on the target population. 73 The objective of this qualitative study was to explore influences on pregnant women's decision 74 making around alcohol use in a population with frequent and heavy peer drinking (i.e. in two 75 Indigenous Australian communities) and another of non-Indigenous pregnant women from a range 76 of backgrounds. The aim was to better understand why messages to abstain may not always be 77 effective with pregnant women and to inform a more tailored approach to health promotion.

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This study used data collected as part of a larger ongoing project, which aims to develop nationally  Women who were pregnant, aged 18 years or older and able to speak and write in English were 90 invited to participate in the study. Recruitment was based on a convenience sample of women 91 attending antenatal care at a date and time that researchers were in attendance. The sites were three 92 public and one private health service in Victoria, Australia, and included socioeconomically 93 disadvantaged and regional areas, as well as two Indigenous Australian settings; one remote service 94 in the Northern Territory and one regional service in Victoria.
Women who met the selection criteria were approached by a member of the research team while 96 they were waiting for their antenatal clinic appointment. Women who were interested in the study, 97 provided written consent to participate and either took part in an individual interview held at a 98 mutually convenient time (mostly immediately following their antenatal appointment) or in a group 99 discussion later that day. Following consultation with clinic staff in the two Indigenous Australian 100 communities, a personal choice to take part in an individual or group interview was offered. This 101 was to allow for freedom of expression where a young woman may not feel comfortable to express 102 her own thoughts in the presence of an elder or may experience shame discussing the topic with 103 others from their community.

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The women taking part in this study had no prior relationship with any of the researchers. All 105 individual and group interviews began with brief introductions to the researchers' background, an 106 explanation of the purpose of the study and an opportunity for the women to introduce themselves 107 with their name and gestational age (e.g. "Hi, my name is Anne and I am 18 weeks pregnant") and 108 ask questions. This was followed by a guided discussion of the women's attitudes towards alcohol

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We interviewed 14 Indigenous Australian pregnant women, three of whom took part in a group 153 interview. In the non-Indigenous setting, we conducted one individual and five small group 154 interviews with two to three pregnant women in each group, totalling 14 participants (Table 1).

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Interviews were undertaken between November 2015 and March 2016. Individual and group 156 interviews ranged between ten and thirty minutes in duration.

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The five main categories in our final analysis matrix were: (1) women's understanding of alcohol-    175 When asked about the harms of alcohol use in pregnancy, all women displayed an understanding 176 and awareness that drinking alcohol was "bad", and generally acknowledged that alcohol use could 177 cause harm to their developing baby. Despite this knowledge, many participants were unclear about 178 the nature of harm to the baby. Some participants were able to describe one or more of the physical, 179 social, emotional or behavioural symptoms such as wide eyes, slow learning and hyperactivity. associated with low or occasional alcohol use was inconsistent and often described low level 185 drinking as being safe.

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Participants often thought that harm was dependent on the timing of alcohol consumption, 187 suggesting there was a "dangerous period" and a "safe period". They generally agreed that it was 188 important not to drink alcohol in the first 12 weeks of pregnancy and following this time, one or 189 two occasional drinks would be unlikely to cause harm to their baby. When thinking about alcoholic 190 drinks, most participants described a drink as being "one glass of wine" or "a beer", showing only 191 limited understanding of the concept of a 'standard drink'.

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Some participants also believed that the type of alcoholic drink consumed played a role in the 193 potential for harm, suggesting that drinks with lower alcohol content such as wine or beer, as 194 opposed to spirits, were safer options.

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Where women obtain information about alcohol in pregnancy (Informing) 196 All participants reported that their knowledge and understanding of harm from drinking alcohol in

How this information influenced their choices (Choosing)
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Study participants used all information available to them to inform their decision-making. children developed normally despite having been exposed to some level of alcohol. In contrast, 223 women who used language that was more directly connected to the developing fetus, such as the 224 "little baby inside", tended to emphasise that abstinence was very important. This language was 225 used predominantly by Indigenous Australian women, but also by some women in rural or low 226 socioeconomic settings.

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Whether the woman's environment supports abstinence (Enabling) 228 Whist Indigenous Australian participants acknowledged that some women in the community, explained that it was common for pregnant women in their community to have "other stuff" going 233 on, such as mental health issues, addiction and domestic violence. They also reflected on having the 234 support of their family and/or partner and the protective value of strong culture. They felt that a lack 235 of community, family and partner support was a clear risk factor for pregnant women to continue 236 their drinking, and that not having a "safe place" to stay was also a risk factor. Indigenous

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Australian participants also thought that young pregnant women in particular were vulnerable to 238 drinking because of a high frequency of unplanned and unwanted pregnancy and trying to keep up a 239 social connection with their friends.

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Although these points were predominantly raised by the Indigenous Australian women, some non-

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Indigenous participants also proposed social and environmental factors. For instance, the social 242 importance of alcohol use, peer-pressure, and not being ready to disclose their pregnancy to others, 243 was thought to impact a pregnant woman's ability to abstain from alcohol.

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This study found some specific influences on pregnant women's alcohol use, which helped to Firstly, the idea that some alcohol was safe to drink after the first trimester, or that spirits were more Consequently, beliefs about the benefits of abstaining from alcohol completely were also low in this 284 group of (non-Indigenous) women and the barriers to taking such action, for example when at a 285 social event, were seen to outweigh any risks.

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For women with unsafe alcohol use or whose social and cultural environment makes abstinence 332 difficult, clinicians can play an important role in supporting and encouraging reduction in intake.

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There is good evidence that brief interventions can be effective. These usually follow the '3 As' of

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The influence of unintended pregnancy, or the time period before pregnancy awareness in general, 349 on alcohol use was not considered specifically in this study and may require additional approaches, 350 such as FASD-specific public health initiatives.