QUESTION
Is the education regarding the consumption of alcohol whilst pregnant provided to young Indigenous women in Karratha adequate?
SOLUTION
There is no level of alcohol which can be considered safe for a pregnant woman. As an expecting female takes in alcohol, it passes on to the foetus through the placenta leading to defects in the foetus. The “Foetal Alcohol Syndrome” is one such defect which is extremely harmful to the baby. The defects not only harm the foetus or the mother, but affect the society as a whole. FAS has an estimated lifetime cost of US 2.9 million per affected individual in 2002. The purpose of this study is to ascertain whether the education being provided to women related to this subject is adequate and also stresses on the lack of support to the health care professionals. The results are gathered from survey conducted on 20 indigenous women of Karratha and will be used to develop an education program, which would be culturally appropriate so that it would be easy for people to inculcate it into their lives.
Aims of the research
The research is conducted through surveying 20 indigenous women of Karratha. The final aim of the research is to develop an education program, which is acceptable by the people of Karratha. For this, the program has to be in accordance with the people’s culture.
The survey is conducted keeping in mind three main aspects, which are as follows:
- Is the education that is being provided to the women of Karratha regarding alcohol consumption during pregnancy adequate?
- Is the training that is being given to the health professionals regarding “Foetal Alcohol Syndrome” sufficient and complete?
- The education program has to be developed in accordance with the people. So, the opinion of the women should be considered as to how the program can be made more culturally sensitive.
Introduction
Alcohol abuse has got serious health effects and can also be fatal. However, in pregnant women, it not only harms the mother, but the foetus as well. In Australia, alcohol consumption is a part of their lifestyle. Alcohol use is embedded in the indigenous way of life and drinking is commenced at an early age (Hayes, 2001). Being such an integrated part of their lives, alcohol is the reason for a number of birth defects. There are a number of reports on alcohol consumption in Australia. One finding which is common to all is the teratogenic ability of alcohol. However, the main area of concern is proper education being imparted to pregnant women. The indigenous women should be educated well enough to understand the effects of alcohol consumption during different semesters of pregnancy and when it is the most harmful.
As the trend of alcohol consumption is culturally embedded in Karratha, a town in Pilbara region of Southern Australia, the remedial education has to be also culturally embedded to be of impact. For this, the women have to be consulted regarding the stages of the program and the program should be developed in a way that it embeds within their culture. When the women would themselves teach their girls and other women regarding the issues of drinking while pregnant, it would have an agreeable impact.
The Foetal Alcohol Syndrome and other problems associated with Alcohol consumption not only affect the baby and its parents, it has a deep impact on the society, as well. With the hereditary trend of the syndrome, it poses as a severe threat to the community. It deteriorates the quality of babies being born, making them physically and mentally unfit to serve the society. According to May, et.al, 2005, a number of second and third generation FAS babies are being born.
This chain of defective babies being born has to be stopped. For this, the education has to be provided at the root level. The problems with alcohol consumption should be included in the study material of primary school kids. This will enable them to completely understand the severity of the problem. Moreover, they will understand how a mother’s action can affect the child. However, one hindrance to this program is that many young indigenous children do not attend schools. In such cases, it should be the responsibility of the elders at home to teach the kids about the problem.
Although, the education regarding alcohol abuse during pregnancy is mainly for the women, education for men is also important. Alcohol has been found to have adverse effects on spermatogenesis and testicular function. (Windham, Fenster, Hopkins and Swan, 1994)
Alcohol abuse and its related problems need to be seriously considered and proper and timely education should be provided to both men and women. This would not only ensure a healthy living, but also do well to the society.
Literature review
Foetal Alcohol Syndrome
A lot of work has been done on alcohol abuse and its effects. Jacobson and Jacobson (1994) reported that drinking alcohol whilst pregnant causes biochemical and structural changes in the developing brain. This affects the brain and also relates to other problems like problems in concentrating, acuity levels and information processing abilities.
The first official definition of the Foetal Alcohol Syndrome came from Elliot, et.al in a paper written in 1968. However, it was published in 2008. As early as 1973, reports from the U.S claimed abnormalities in children born to alcoholic mothers. The symptoms associated with this syndrome are abnormal facial features, pre and/or post natal growth failures, central nervous system dysfunction, etc. ( Payne,et.al 2005, Peadon,et.al. 2007).
Through the in-utero alcohol exposure, the effects on the foetus range from mild to severe. Both major and minor effects in the children have been observed. Children exposed in-utero to alcohol are born with characteristics along a continuum from mild abnormality to extremely severe disability.
Children with known alcohol exposure have been found to have other features consistent with alcohol related birth defects such as muscoskeletal abnormalities, spina bifida, cardiovascular abnormalities, renal abnormalities, cleft palate and microphthalmia (Elliott et. al. 2008). The term foetal alcohol spectrum disorder (FASD) is now being used commonly in the field of health care. It is a label being given to children exhibiting intellectual disability, retarded growth, learning and behavioural problems, and some physical abnormalities (usually facial).
There are two main factors determining the severity of the problem. These are:
- The quantity of alcohol intake
- The time period of pregnancy during which alcohol is consumed
Coles (1994) postulates that many questions regarding the effects of alcohol on the foetus centre around the timing of a mother’s consumption of alcohol and the duration of the foetus’s exposure, whether the foetus is exposed early or late in the pregnancy and whether it makes a difference if the mother discontinues drinking for the duration of her pregnancy.
Quantity of alcohol
In spite of the known fact of alcohol being teratogenic, there is continuing debate on whether alcohol consumption is safe during pregnancy. Scientists are still uncertain about the level of alcohol which can be considered safe. Due to variations from person to person, the scientists have been unable to ascertain at what level of alcohol consumption, the impairments occur. According to Jacobson & Jacobson (1994) add this is because the body has the ability to cope with low doses of toxic substances and that defects are only seen once this dose is exceeded. The new NHMRC guidelines promote and advice abstinence from alcohol. This advice is however based on uncertainty and not science (Pyett et. al., 2008).According to research, the threshold values for symptoms like craniofacial defects, mental retardation and foetal death has been found to be quite high. These effects have been seen only in foetuses exposed to very high alcohol levels. However, Peadon et. al., 2008 says that alcohol consumption during pregnancy can lead to still birth, miscarriage, prematurity, birth defects and problems with growth and development.
Wilson (2006) affirms that although all around the world, people advice that it is safe to drink in moderate amounts, there is no” safe level” of alcohol whilst pregnant. According to Coyne, et. al., 2008, till date no well defined criterion has been developed to determine the safe level.
Pyett et. al (2008) add that scientists still do not have good knowledge on how small amounts of alcohol effect the foetus. However, through research it has been ascertained that even low alcohol levels can have a detrimental impact on the baby. It has also been found that a woman who has given birth to an alcohol affected child has a 70% probability of giving birth to a second alcohol affected child indicating that some women may be more susceptible to having FAS children (Abel and Sokol, 1987).
The below given table summarises the work done by different people on the quantity of alcohol intake whilst pregnant.
| S.No. | Reference | Finding |
| 1. | Jacobson & Jacobson (1994) | The body has the ability to cope with low doses of toxic substances and that defects are only seen once this dose is exceeded. |
| 2. | Pyett et. al., 2008 | Due to uncertainty, abstinence from alcohol is advised. Even low levels of alcohol can affect the foetus. |
| 3. | Peadon et. al., 2008 | Alcohol consumption during pregnancy can lead to still birth, miscarriage, prematurity, birth defects and problems with growth and development. |
| 4. | Wilson (2006) | There is no safe level of alcohol whilst pregnant. |
| 5. | Coyne, et. al., 2008 | There is no criterion developed to determine the safe level of alcohol consumption. |
| 6. | Abel and Sokol, 1987 | Some women are more susceptible to having FAS children. |
Hence, following the uncertainty principle, even low doses of alcohol should be avoided. There is no level of alcohol which can be said “safe’ with conviction.
Time period of alcohol consumption
The time period during which alcohol is consumed is another important factor. However, studies for this factor on humans is difficult. Hence, most of the research is based on animals. The results shown on the animals are valid for humans, as well. Stratton, Howe and Battaglia (1995) add that there have been excellent results obtained from animal studies relating to FAS and gone a long way to improving our knowledge in the area.
It has been suggested that the best way to discover how timing affects pregnancy outcome is to gather information regarding exposure throughout gestation (Coles, 1994). This means that different foetuses should be exposed to alcohol doses during first, second and third trimesters. However, the dose has to be the same. Coyne, De Costa, Heazlewood and Newman (2008), Walpole and Hockey (1980) add that heavy alcohol and binge drinking use in early pregnancy has been linked with the facial abnormalities and neurological malformations associated with FAS and retarded growth, cognitive and behavioural abnormalities have been linked with heavy alcohol use later in pregnancy.
In a study based in Settle, mothers were interviewed during their gestation period on alcohol habits prior to and during pregnancy. It was concluded that drinking in the early part of pregnancy was more dangerous. According to Coles (1994), early exposure to alcohol led to mental retardation, motor and sensory dysfunction, etc. Ernhart, Sokol, Martier, Moron, Nadler and Ager (1987) also suggest that statistical studies of craniofacial anomalies in children exposed to alcohol prenatally have indicated a relationship exists between craniofacial anomalies and exposure in the first trimester. Contrary to this, Jacobson et. al. (1994) found that neurobehavioral effects were worse if the foetus was exposed to alcohol later in pregnancy rather than at the time of conception.
The below given table summarises the work done by different people on the time of alcohol intake whilst pregnant.
| S.No. | Reference | Finding |
| 1 | Stratton, Howe and Battaglia (1995) | Excellent results are obtained from animal studies. |
| 2 | Coles, 1994 | Early exposure to alcohol led to mental retardation, motor and sensory dysfunction, etc |
| 3 | Coyne,De Costa, Heazlewood and Newman (2008), Walpole and Hockey (1980) | Heavy alcohol and binge drinking use in early pregnancy has been linked with the facial abnormalities and neurological malformations associated with FAS and retarded growth, cognitive and behavioural abnormalities have been linked with heavy alcohol use later in pregnancy. |
| 4 | Ernhart, Sokol, Martier, Moron, Nadler and Ager (1987) | There exists a relationship between craniofacial anomalies and exposure in the first trimester. |
| 5 | Jacobson et. al. (1994) | Neurobehavioral effects were worse if the foetus was exposed to alcohol later in pregnancy rather than at the time of conception. |
Role of health care professionals
The health care professionals need to be careful regarding the stigma associated with FASD. According to Pyettt, Waples-Crowe, Hunter Loughron and Gallagher (2008), it is a category in which children are put into when they have problems in school or when they are placed into foster care. The symptoms can be due to other reasons like a child’s background, etc. The fear of such a label may also discourage women from attending health services. It is at this point that a health care professionals’ role comes into play.
In the absence of any conclusive research, it is the duty of the health care professionals to advise complete abnegation from alcohol. The women should not be confused and only one message should be conveyed.A study conducted in 1987 in Western Australia reported that 30 % of women had been given advice about alcohol consumption whilst pregnant and that the advice given was “to cut down” not to abstain even though abstinence was the recommendation in 1987 by the National Health and Medical Research Council (Payne et. al 2005); Blaze-Temple (1992) and Blaze-Temple, Carruthers, Knowles and Binns (1992). This presents pregnant women with two conflicting schools of thought regarding the consumption of alcohol whilst pregnant.
Prevention through education and knowledge
For development of effective programs, two main points are:
- The health care professionals should be sure of the facts
- The programs should be targeted to specific groups
Majella et. al. (1999) compared five prevention programs. The study was done across a range of populations, school, pregnant women, community samples and indigenous groups. They consisted of a telephone survey, antenatal screening questionnaires, a survey and computer administered questions at an antenatal clinic. They reported that all studies found increased knowledge levels after the programs were completed and supported public prevention campaigns. It wa found that in spite of the methodological flaws like studies aimed at only specific groups of people, all studies found an increase in awareness of FAS.
Another study was done by France et. al. In 1996, where 19 in-depth interviews were conducted from health professionals from different specialties. In this, a focus group approach was followed. It was felt a focus group approach would create optimal homogeneity within the group and optimal heterogeneity between the groups, so participants felt secure enough to voice opinions.The outcome of this study was that the health professionals felt that they were not updated.
Another study highlighting that the health professionals perceived lack of knowledge in this area was conducted by Payne et. Al (2005). Hayes (2001) asserts an effective model targeting young children who are continuously exposed to negative adult behaviour needs to be developed. Massotti et. al., (2006) add that a sense of “community ownership” is crucial for the acceptance and effectiveness of any program. Majella et. al (1999) add it is preferable that young women are be educated at an early age, beginning at school, before they become sexually active so that they are aware of the dangers of drinking alcohol on the unborn child.
Prevention is however better than intervention. Heath care professionals need to be fully aware of FAS and the effects of alcohol consumption. They need to be provided with the latest developments and technologies.
Alcohol use and incidence of FASD in Australian Aboriginal Communities.
According to Majella et. al, FAS is not limited to Indigenous communities but it is present worldwide and in larger numbers but tends to be more evident in the socio-economically disadvantaged sections of the society. In Australia, rates have been found to be significantly higher in the Indigenous communities. According to the West Australian birth defect registry, The non- Indigenous rate is 0.02 per 1000 births but the rate of FAS in the Indigenous community was much higher 2.76 per 1000 births which is over 100 times the non- Indigenous rate. Also, according to Peadon et. Al (2008), the incidence amongst Indigenous Australians is much higher at 2.76 to 4.7 per 1000 live births.
Pilot study
Framework
The theoretical framework for this study has been drawn from Hayes (2001)- Life Cycle Model. It takes all the interconnecting and interacting complexities of life that feed into to the cycle of life, which feeds into the environment , and feeds from the environment (Hayes, 2001). The model begins 0-2 years and continues around to when a person reaches adulthood. It also depicts life stages which a person goes through.
Methodology
This study followed a “qualitative” research approach. The participants drawn are from specific and vulnerable populations. Data was collected through the completion of a questionnaire during individual interviews. Information was gathered at one point in time. To make the women comfortable, information was collected at their homes or other places of their choice. The questionnaire comprised of 7 questions, which addressed the women’s perceptions on the following:
- The Foetal Alcohol Syndrome
- Relevance of any information provided to them
- The cultural suitability of the information
- The women’s perceptions of where and when education on the topic should be provided
The number of women being interviewed was 20 and Confidentiality was maintained during the study by obtaining the data in an individual interview.
To start with, an information sheet was provided to the women. Only after their approval, the questionnaire was given.
The budget of the study was $1500, which comprised of costs of stationery, telephone expenses, fuel costs, refreshments for participants, etc.
Limitations of the study
The following points give a description of the limitations associated with the study:
- Poor response rate to the questionnaires would effect comparison and validity of results.
- Self –reporting can also be flawed as participants may feel a need to conceal information due to feelings of shame, fear of accusations or blame.
Conclusion
Any education and awareness program which is culturally linked with the society and involves the local people is viable. The main point is that the professionals should have a specific goal and should be clear in their thoughts. They should also be updated about the regular developments.
Appendix 1
| Question 1-Can you tell me what you know about drinking alcohol whilst pregnant. | ||
| Causes miscarriage | Harms the baby | |
| Makes baby slow | Makes baby sick | |
| Brain Damage | It’s wrong | |
| Makes baby sick | Makes baby slow in the head | |
| It’s very bad | Can make the baby drunk | |
| Causes problems for the baby | Do not know much about it | |
| Face changes- deformed | It’s not good for the baby | |
| Not ok to drink | Unhealthy for mother and baby | |
| Can kill the baby | Learning problems. Makes baby slow | |
| Makes baby retarded | Do not know | |
| Question 2-Can you tell me about any in formation you might have received whilst pregnant; who provided it and when was it provided. | Told not to drink and smoke by mother | Did not get any information, drank to be involved with my family, doesn’t hurt as long as it is not all the time . |
| Told to eat healthy by doctor | Told it makes the baby drunk-is that true? By family | |
| Told about dangers of drinking by doctor | No information, drank some alcohol when pregnant, women in my family all did and their babies were ok. Just don’t get really drunk. | |
| Given information at school before I was pregnant. | Grandmother spoke to me about it when I found out I was pregnant | |
| Given info by community nurse when I was 3 months pregnant. | Told by community nurse it could make the baby look funny and be slow, but i still drank from time to time. | |
| Given information by doctor which I didn’t really believe as lots of women drink while pregnant and their babies are ok. | No information given but have seen pamphlets in health centre | |
| Health worker told me I had to stop drinking and look after myself and my baby | Have seen posters but don’t remember where | |
| Told by doctor at Aboriginal Medical service (AMS) that alcohol makes babies sick and that what I do to my body affects the baby. | No education | |
| Given no information. | Was asked by doctor if I drank and when I said “yes” he said a little was ok as long as I did not get drunk | |
| Told by health worker to look after myself better than I normally would. | Do not know when info provided spoke to community nurse when pregnant | |
| Question 3- Can you tell me if the information was helpful | Not really | A little bit |
| Very helpful, I never drank whilst pregnant | No as no info given | |
| Made me stop drinking | No as no info given | |
| Yes | No | |
| I didn’t take much notice | No | |
| Yes | Made me stop | |
| Made me think about looking after myself better as well | Yes | |
| No | Yes | |
| Yes I learned that what I do, I do to my baby as well | A bit | |
| Yes | Yes | |
| Question 4- Can you tell me if the information was culturally appropriate?
|
Unsure | No |
| Yes- Aboriginal and white fetal alcohol syndrome doll (FAS) baby doll shown to class | No | |
| Yes- nurse was very caring | Yes- Aboriginal people in the posters and pamphlets | |
| Yes- I was shocked by the damage it can do to the baby – doctor was good | Yes | |
| More info should be given | Yes | |
| Yes | Yes- doesn’t matter who provides the information as long as you get it | |
| Unsure | No | |
| Not really | Don’t Know | |
| Not really | Yes | |
| In some ways | No info received | |
| Question 5- When do you think is the right time for people to receive information regarding drinking alcohol whilst pregnant? | Before getting pregnant | Before pregnant |
| Before getting pregnant | Don’t know | |
| Before getting pregnant as I would of known to stop | When early pregnant | |
| Before they pregnant | First 3 months | |
| At school before they have sex | Before start having sex | |
| When they get pregnant | As soon as they know they are pregnant | |
| First few months of being pregnant | Unsure- don’t really need it, alcohol is ok if you don’t drink all the time. | |
| Before pregnant | Before they start having sex | |
| When pregnant | Did not answer | |
| Before they want to have a baby | At check up | |
| Question 6- Where do you think people would be more comfortable receiving information? | At home | At the doctors |
| Anywhere | Aboriginal Medical Service | |
| Anywhere | Home | |
| School | Anywhere | |
| School | Anywhere | |
| Home | With women in the community | |
| School | School | |
| Doctors | Home | |
| Aboriginal medical service (AMS) | Home not in front of men | |
| School | Where ever a person goes for check ups. | |
| Question- 7 Do you think that it would be helpful for boys to receive this information as well as girls? | No | Yes |
| Yes they are part of it | Yes | |
| No it’s women’s stuff | No | |
| Not sure | No- shame | |
| Yes as they going to be fathers | No women’s business | |
| Yes | No Shame | |
| Yes | Yes alcohol could damage sperm and hurt baby | |
| Unsure | No women’s business | |
| Yes | No | |
| Yes they need to be able to help | Yes |
References
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Coles. C. (1994). Critical periods for prenatal alcohol exposure. Evidence from animal and Human studies. . 18(1), 22-29.
Coyne, K., De Costa, C; Heazlewood, R., & Newman, H. (2008). Pregnancy characteristics of women giving birth to children with foetal alcohol syndrome in Far North Queensland. Australian and New Zealand Journal of Obstetrics and Gynaecology. 48,240-247.
Elliott, E., Payne, J., Morris, A., Haan, E., & Bower, C. (2008). Foetal alcohol syndrome: a prospective national surveillance study. Archives of Disease in Childhood. 93, 732-737.
Ernhart, C., Sokol, R., Martier, S., Moron, P., Nadler, D., Ager, J., & wolf, A. (1987). Alcohol teratogenicity in the human: A detailed assessment of specificity, critical period and threshold. American Journal of Obstetrics and Gynecology. 156(1): 33-39
France, K., Henley, N., Payne, J., D’Antoine, H., Bartu, A., O’Leary, C., Elliott, E., & Bower, C.(2010). Health Professionals addressing alcohol use with women in Western Australia: Barriers and strategies for communication. Substance Use and Misuse. 45, 1474- 1490.
Hayes, L. (2001). Grog babies: where do they fit in this alcohol life cycle? Aboriginal and Islander Health Worker Journal. 25(2), 14-17.
Jacobson, J., & Jacobson, S. (1994). Prenatal alcohol exposure and neurobehavioural development: Where is the threshold? Alcohol Health and Research World. 18(1), 30-36.
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Massotti, P., George, M., Szala-Meneok, K., Morton, A., Loock, C., Van Biber, M., Ranford, J., Fleming, M., & McLeod, S. (2006). Preventing foetal alcohol der in aboriginal communities: A methods development project. PLos Med. 3(1),e8.
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Payne, J., Elliott, E., D’Antoine, H., O’Leary, C., Mahony, A., Haan, E., & Bower, C.(2005).Health professional’s knowledge, practice and opinions about foetal alcohol syndrome and alcohol consumption in pregnancy. Australian Journal of Public Health. 29(6), 558-564.
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Stratton, K., Howe, C., & Battaglia, F. (1995). Diagnosis, Epidemiology, Prevention, and Treatment. Report Summary Fetal Alcohol Syndrome. Committee to Study Fetal Alcohol Syndrome. Division of Biobehavioural Sciences and Mental Disorders. Washington DC: National Academy Press.
Wilson, S. (2006). Foetal alcohol spectrum disorders: an update. Aboriginal and Islander Health Worker Journal. 30(6), 6-7.
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