In January 2016, the Chief Medical Officers (CMO) of the UK published new joint guidance on low-risk alcohol consumption. This included revised guidance for the general population as well as specific recommendations relating to alcohol consumption for women who were pregnant or planning a pregnancy. Following an evidence review, a revised low-risk threshold was issued for men, down from no more than 21 units per week to no more than 14. The advised threshold for women was maintained at no more than 14 units per week. For women who were pregnant or planning a pregnancy, a precautionary approach was adopted, meaning a recommendation that these women should abstain from alcohol completely.
The aim of this research was to understand how the new CMO guidance on pregnancy was received by the target audience. Study methods were a rapid evidence review on alcohol and pregnancy, followed by a document analysis of CMO guidance and background documents. Four focus groups were then convened with a total of 18 stakeholders (Policy, Midwifery, Parents, Parent advocates), involving a presentation of key findings of the evidence review followed by group discussion.
Interpretations of the precautionary principle
The new guidance for alcohol in pregnancy is underpinned by a ‘better safe than sorry’ precautionary principle, but the rationale is not clearly explained. In consequence, participants felt users rationalise for themselves. Some conclude that the advice is intended to provide extra protection to the foetus, to simplify communication, or to support more vulnerable, or less educated women, who may struggle to interpret complex evidence. Some believe that it is meant to provide a strong message about alcohol at a ‘teachable moment’, leading to longer-term health benefits.
Clarity versus accuracy
Midwives and some new mothers appreciated the clarity of a simple abstinence message. However, other participants, including new mothers and third sector workers, felt that this failed to properly reflect the complexity in the evidence on low level drinking in pregnancy. Some felt the lack of nuance in the abstinence message would not be acceptable to all women, especially if they were aware of the evidence base or encountered alternative interpretations via other information sources, such as online forums. This could lead to mistrust of health guidance more broadly, or of midwife advice specifically.
Interaction with pregnancy planning
Guidance to abstain from drinking while planning a pregnancy is incompatible with many women’s lived experiences of pregnancy planning (or un-planning) in a culture of social drinking. Drinking before becoming aware of pregnancy is commonplace and participants were dissatisfied with reassurance over this in the guidance. Some believed the guidance could cause undue anxiety where a woman had drunk alcohol prior to knowing she was pregnant. Others were concerned that midwives could find themselves providing false reassurance if a woman had consumed a more significant amount.
Policing pregnancy
Participants felt that the message could increase the likelihood of social surveillance of women’s alcohol consumption. Several felt that social shaming was implicit and that the ‘no drinking in pregnancy’ logo on containers may increase the likelihood that pregnant women’s behaviour would be subject to increased social ‘policing’. Several participants described direct (and negative) personal experience of this.
Ecological reach
The guidance contains limited recognition of the UK’s culture of social drinking, of social loss associated with abstinence and of the social network pressures and influences affecting choice. All participants agreed that women who had made a decision not to drink in pregnancy, or to drink at low levels, appreciated support from members of their social networks, and that encouraging this could be better built into guideline communication. For example, encouraging partners of expectant mothers to cut down or stop drinking for the duration of the pregnancy would be helpful. So too would the better provision of alcohol-free alternatives in the range of social contexts pregnant women may find themselves, or where they may otherwise feel excluded (e.g. pubs).
Communication
The rationale for a precautionary approach should be transparent in guidance documents and supporting information. Guidance on health-related behaviours for the general population tends to be rights-based, enabling individuals to weigh risks and benefits in the context of recommendations; caution and clear justification are needed where a different approach is taken. Principles of honest communication and clear risk presentation should underpin all messages.
Layering of explanations
Where the evidence is not straightforward, communication should take account of this and include opportunities for users to consider the available information. This could be achieved by taking a layering approach, enabling users to access information to a depth that suits their own needs. Health professional bodies and third sector organisations should consider strategies to facilitate this.
Acknowledging the reality of pregnancy planning
Guidance documents should recognise the lived experience of ‘pregnancy planning’. The complexity of this is not currently represented realistically.
Clarifying intentions and avoiding social shaming
The aims of the guidance should be clearly specified. The development of communication strategies should consider the risk of both social shaming and associated anxiety. Strategies could include providing professionals with tools for managing conversations with women and family members and for re-framing advice in positive terms – emphasising, for example, that there are ‘no benefits to baby’ from drinking, or that there may be benefits of abstention to mother and her partner.
Consider a social network message
Ensure communications include family members and partners, highlighting the influence of their own behaviour and the benefits of social support. Promote a reframing of the role of alcohol in social contexts so that abstention is no longer considered abnormal.
Research social impact of message as part of guidance development
A consultation on guidance communication took place following guidance development, however this did not test the perception of advice in the context of ‘real-world’ social drinking and pregnancy planning. Further research with target audiences is recommended, taking into account learning from behavioural psychology, health communications etc. This consider values underpinning the public health messages, unintended negative effects, appropriate message targeting and alternative message framing.
The current guidance is grounded in a biomedical approach, but communication and advice should reflect the fact that drinking in pregnancy is a socio-ecological issue. The impact of guidance on alcohol consumption when pregnant or planning a pregnancy may be limited by many factors, including lack of clarity over the evidence, limited acknowledgement of ‘lived experience’ and lack of recognition of the influence of social networks.
Contact details for corresponding author:
Dr Rachel Brown, DECIPHer, 1-3 Museum Place, Cardiff, CF10 3NB
