Taking responsibility for own health

An interesting theme to emerge inductively from the data was women’s desire to take responsibility for their own health. Women wanted to make individual choices and take control over decisions about their own health.

“I think it has to be everyone’s individual decision certainly.” (Interview 5, one child)

Participants felt that women who wished to drink more than advised could make that decision and should take responsibility for their actions. In addition, women demonstrated concern that the government and public services were attempting to control how pregnant women acted and were making choices on their behalf.

“I think we’re all responsible enough to… I think there is too much bureaucracy and too much red tape around things.” (Interview 14, two children)

Women felt they were not given the opportunity to make an informed decision about their own health and the health of their unborn child. They recognised the need for more informative advice in order for women to take responsibility for themselves.

“I generally feel that women should be given the information about… what is known, and the risks etc. and then left for them to make up their own minds.” (Interview 9, no children)

DISCUSSION

This qualitative study revealed diverse attitudes towards alcohol consumption during pregnancy among well-educated women. Women were found to have differing views on the risk associated with drinking alcohol and this influenced their consumption of alcohol. Their evaluation of risk was hindered by the availability of often conflicting advice from government guidelines, health organisations and the media. In addition, women often reported that they had not received individual advice from health professionals. This may have encouraged women to rely on anecdotal advice from family and friends, and experiences of past pregnancies. However, many women reported that they wanted official advice and guidelines.

In keeping with previous research, women had considered the potential risks to their unborn child from drinking alcohol during pregnancy and this often affected their attitudes towards drinking [26]. Higher perceived risk is associated with lower alcohol consumption in pregnancy [27]. Moreover, in keeping with surveys carried out in other countries, most women in our sample reported they had reduced their alcohol consumption following pregnancy recognition [26,28]. However, almost three quarters had consumed alcohol while pregnant which is in keeping with UK national statistics [29]. Their attitudes toward drinking alcohol during their current pregnancy were often influenced by experiences of other pregnancies, perhaps through evaluation of risk [27]. Many women recalled their levels of drinking in their previous pregnancies or those of family and friends and felt there had been no adverse influence on the child’s health. Interestingly, some women described positive effects of drinking in pregnancy such as stress relief and often mentioned missing alcohol if they had reduced their consumption. As antenatal anxiety is a risk factor for child mental health problems [30], some women might perceive that the possible benefits of drinking during pregnancy might outweigh the potential risks. Furthermore, since our data were collected, there has been recent media interpretation and reporting of findings from a large study that drinking 1-2 glasses of alcohol a week during pregnancy could boost a child’s intelligence and behaviour by the age of three year [8]. This is likely to have added to the uncertainty and confusion for pregnant women in the UK.

We also explored women’s attitudes towards sources of information relating to alcohol consumption in pregnancy. Although most women were aware of some form of advice or information about this, their knowledge of the source and content of the information and their attitudes toward the advice differed considerably. Many women reported conflicting information from the media. Unsurprisingly, common views were that the information was confusing, unclear, or lacking in sufficient detail. In keeping with findings from other countries, health professionals reportedly offered limited or inconsistent advice to pregnant women, often not raising this issue at all [20,21,31]. A possible explanation is that health professionals are not certain whether abstinence from alcohol in pregnancy is necessary and that they are also similarly confused [32]. However, information and advice from health professionals are regarded as influential and persuasive and participants reported that more would be welcomed [21,33]. Furthermore, since there is clear evidence that alcohol has negative effects on infant development if consumed in sufficient quantity [1], it is particularly concerning that ambiguity in terms of safe limits may have deterred health professionals from offering any advice about limiting alcohol intake. This is an area that warrants further research.

Methodological Issues

The purpose of this qualitative study is to provide information on women’s attitudes towards alcohol consumption in pregnancy. As with other qualitative research, there are questions of information bias, reliability of results and validity of explanations. Different approaches to analysis may have yielded some differences in the findings. Attempts to reduce these effects included using a consensus approach to identifying themes with multiple researchers and checking inter-rater reliability for these themes. Although face-to-face interviews have the advantage of eliciting non-verbal information, telephone interviews were practical and conveniently fitted around the participants’ lives. In addition, although women may have been more open in a relatively anonymous telephone interview compared to a face-to-face interview at an unfamiliar location, the direction of effect in terms of the confiding of sensitive information remains unclear [34]. For example, worry or guilt did not emerge as a theme in the study. Although the information given may have been influenced by the interviewer being male, the direction of influence is unclear. A range of diverse views were elicited, suggesting that it is unlikely that researcher bias had a major effect.

The findings from this exploratory study should be regarded as preliminary. Information about advice received about drinking during pregnancy was ascertained using closed questions and hence was not part of the thematic analysis. In terms of the sample, we were not able to collect information about why women chose not to participate in the study. We recruited from a range of groups in order to increase variation within the sample. Although we did not obtain information on their ethnicity or employment status, it is likely that sampling through groups may bias the sample towards more socially integrated women. Indeed, the majority of participants had a university education and were married and so their attitudes and drinking levels may differ from other women. For example, older, more highly educated mothers with children are more likely than other women to drink lightly during pregnancy [6,8,26]. Hence the issue of light drinking is salient. Despite our relatively homogeneous sample, women represented in this study reflect an important group. Exploring the views of these women provided important insights into their attitudes towards drinking during pregnancy and current advice and their desire for further information.

Future research

In order to explore a broader range of knowledge and attitudes towards alcohol and influential sources of information, future research should incorporate more diverse samples. Our findings can provide the basis for a larger quantitative survey in the UK to assess pregnant women’s attitudes towards alcohol and their drinking behaviour. It would also be useful to formally investigate how information is presented in the media and is provided to pregnant women by health professionals. Our study highlights the need for a similar study with GPs and midwives in order to establish their views about alcohol use in pregnancy and the provision of information. This may provide an explanation for women’s perceptions of only limited advice being provided by health professionals. Comparative studies from other countries would enable cross-national comparisons of attitudes and perceptions of advice and drinking during pregnancy.

Clinical and Policy Implications

Many women described the importance of personal choice in relation to health decisions in pregnancy. They also called for individual advice from health professionals and felt they would have found this useful. As alcohol consumption prior to pregnancy recognition is a common occurrence [13], health professionals should be aware that many women may seek reassurance.

Government policy makers and health professionals should recognise the importance of these issues to women who might drink socially during their pregnancy, especially as research on safe levels of drinking in pregnancy remains inconclusive. Our findings suggest that they need to ensure that pregnant women receive accurate and consistent information on which they can base decisions and take responsibility about their healthcare. They should be aware that women consume alcohol for a range of reasons, including relaxation, and advice needs to account for women who plan to continue to drink during pregnancy. The challenge for policy makers is to provide clear, consistent and credible information for both pregnant women and health professionals in contact with them.