1. PARENTS’ AND MIDWIVES’ VIEWS OF PREGNANCY DRINKING GUIDELINES IN ENGLAND AND SWEDEN - COMMUNICATION AND RISK PERCEPTION Lisa Schölin BSc, MSc PhD Student Liverpool John Moores University, UK Birmingham, March 2016

2. OVERVIEW ➤ Background ➤ Risks with drinking in pregnancy ➤ Drinking guidelines - precautionary principle ➤ Methods ➤ Findings ➤ Parents ➤ Midwives ➤ Discussion

3. BACKGROUND ➤ Alcohol can harm the developing foetus ➤ High levels of drinking - Fetal Alcohol Syndrome ➤ No conclusive evidence of harm at low to moderate levels (Henderson et al., 2007; Patra et al., 2011; Polygenis et al., 1998)

4. WHAT IS SAFE?

5. PREGNANCY GUIDELINES ➤ Precautionary approach in many countries – ‘no alcohol no risk’ ➤ England: until January 2016 ‘low risk guidelines’ ➤ Avoid all alcohol in the first trimester ➤ After first trimester no more than 1-2 units once or twice per week ➤ Not binge drink (>7.5 units) ➤ Sweden: complete abstinence - precautionary principle has precedence for the wellbeing of the baby

6. PRECAUTION AND RISK ➤ Criticism towards ‘policing pregnancy’ - with no conclusive evidence of risk at low to moderate levels why advise abstinence? (Lupton, 2012; Gavaghan, 2009) “the shift from ‘estimation of risk’ to the ‘precautionary principle’ is a part of a wider socio-cultural push towards broader employment of the precautionary principle as a strategy to manage uncertainty, and in the context of pregnancy, it is a part of the symbolic struggle to protect the purity of the foetus and construct the ‘perfect mother’” (Leppo et al., 2014)

7. PHD RESEARCH ➤ Cross-cultural, Mixed Methods project (collaboration with Örebro University, Sweden) ➤ Aim to explore differences and similarities in country promoting abstinence versus lower limits in regards to: ➤ Practices ➤ Perceptions ➤ Prevention ➤ Cross-sectional survey (N=347) ➤ Interviews (N=60) ➤ 44 parents ➤ 16 midwives ~1.4m ~290,000

8. QUALITATIVE METHODOLOGY ➤ Semi-structured interviews ➤ Focus on exploring Knowledge, Attitudes, and Practice ➤ Parents: ➤ Recruited through social media, parent support groups, Children’s Centres (England), GP practices (Sweden), and informal networks —> snowball method ➤ Child <18 months ➤ Midwives: ➤ Recruited through one local maternity service in Merseyside and across the regional maternity services in Örebro County

9. SAMPLE Parents ➤ n: 22 (Eng) and 22 (Swe) ➤ Mean age: 32 (Eng) and 30 years (Swe) ➤ Married: 72% (Eng) and 32% (Swe) ➤ University degree: 68% (Eng) and 73% (Swe) ➤ First child: 68% (Eng) and 41% (Swe) Midwives ➤ n: 7 (Eng) and 9 (Swe) ➤ Mean age: 48 years (Eng and Swe) ➤ Mean years of experience: 17 (Eng) and 14 (Swe) - ranged from 26 years ➤ Place of work: 7/7 urban (Eng) and 5/9 urban (Swe)

10. WHAT WERE WOMEN TOLD? “They probably just asked the question ”what is your view on this thing with alcohol” and then said that ”no I am not going to drink anything”, like why do they ask the question! And like “no, no that’s good you shouldn’t drink when you are pregnant” (Swedish Woman 16, 27 years, first child) “I think generally they, because it’s such a grey area they gave they grey. So they sort of said “there’s more evidence to say not but it is advised not to, but a glass of wine is (inaudible)” they didn’t say definitively don’t have a drop or definitely do. They sort of left it to our decision, so left it to (wife’s name) to make that decision but I wasn’t going to make that decision” (English Partner 1, 27 years, second child)

11. ABOUT RISK ➤ Swedish parents - highly risk averse and believed it to be part of culture not to drink in pregnancy ➤ Half of interviewed English women drank, most at low levels at special occasions ➤ Majority did not believe low levels would necessarily harm, even if decision to avoid alcohol ➤ Intoxication as benchmark of risk/irresponsible behaviour ➤ Drinking among a few described as a treat, part of non-pregnant self

12. RELATIVE RISK? A friend actually had a quarter of a bottle of Jägermeister and smoking joints ehm a couple of days before she gave birth in February so she was quite heavily pregnant and she was necking it […] when I got pregnant and when we started cutting down it was like “but at least I am not doing that, at least I’m not necking Jägermeister with her (the baby) inside of me” it’s… I know a lot of people do it. I know a lot people forgive themselves for it, I don’t think I’d be able to. If I was that reckless and decided that I‘d be drinking loads of alcohol ehm I can’t judge anyone who has done it because again, it’s worse with people who are on smack, crack cocaine. You know anybody who told you that they drank every day in pregnancy, you know it could be much worse. English woman, 24 years, first child

13. WHAT DID MIDWIVES ADVISE? ➤ All midwives recommended women to abstain completely ➤ Skepticism among English midwives if small amounts is harmful - opposite in Sweden “You can inform them and say you know, but in the back of your mind you go “one’s not gonna kill ya” but I prefer to say no, no drinking” (English midwife 5) ➤ Adapting and tailoring to the individual was an important aspect

14. GUIDELINES - MISINFORMATION AND CONFUSION “I would say that in my general opinion that most women have a little of alcohol during pregnancy partially because the information that we give them is very, you know misinformation really, the guidelines have changed and every year we seem to be giving them different information about alcohol what’s safe and what’s not safe so I think it’s really confused as a professional to be honest” (English midwife 4) Well we know that the risks are but we don’t know what level would be at risk, so I would give the information, I think that we should all be singing from the same hymn sheet (English midwife 7)

15. DISCUSSION ➤ Cultural differences in risk perception - facilitates the uptake of a precautionary approach ➤ New drinking guidelines - how do we communicate with skeptical audience? ➤ Encouraging that midwives say they recommend abstinence, BUT; there are multiple versions of advice being communicated ➤ Not all parents were convinced small amounts is harmful - clear information on rationale for guidelines is needed ➤ Findings support the change to abstinence advice, as ‘low risk’ guidance seem to create confusion (Raymond et a., 2009), BUT; ➤ Need to appreciate that women make decisions about drinking in relation to many different factors (risk, social events, pleasure) (Ford, 2013)

16. Supervisory Team Dr Lorna Porcellato Professor Karen Hughes Professor Mark Bellis Professor Charli Eriksson @lesaangelic a L.A.Scholin@2012.ljmu.ac.uk