This is the second blog of six where Professor Moira Plant shares highlights from her report to be published this summer.
Who is most likely to drink during pregnancy and what gets in the way of discussions about it?
This second blog in the series (see the first blog here) shares highlights from the forthcoming report on Women, Alcohol, Pregnancy and FASD. It focuses on some of the factors explaining why a woman might drink during her pregnancy. It will also look at some of the things that help, or hinder, professionals in discussing any patient’s drinking history and habits. My report includes extensive references to the relevant research.
So, who is most likely to consume alcoholic beverages while pregnant? Sometimes it’s women who have already been drinking for a number of years. This can be for a wide variety of reasons, from enjoyment to peer pressure. Many use alcohol as a way to self-medicate. Women who have faced adverse childhood experiences and women who have mental health issues (such as depression and/or anxiety) are more likely to continue drinking.
Having worked as an alcohol specialist nurse (and then as a psychotherapist) for many years, the links between drinking in pregnancy and childhood experiences of abuse, mental health and wellbeing concerns are clear to me.
Back when I was working in an Alcohol Treatment Unit, we paid little attention to the possibility and risks of prenatal alcohol exposure. Looking back, I feel quite uncomfortable remembering some of the interactions I saw with mothers. When a woman said her children were not sleeping or eating properly, or had significant behavioural difficulties, it was often dismissed. The assumption was that her drinking was preventing her from setting boundaries and being a ‘good mother’.
Many of these women had been abused as children or young people and had developed a weak sense of agency, and a strong sense of worthlessness. It was not unusual for them to be in relationships with abusive partners, often feeling grateful to be in a relationship of any kind. Depression is common for a woman in this situation, and she may drink to dull the pain and cope with the unhappiness in her life.
For women in such relationships arise if they threaten to leave or if they become pregnant. Abusive partners may think a pregnancy or child will diminish their control or divert the woman’s attention. They do not want to lose their sense of dominance and may have no desire for a pregnancy.
When describing their lived experience to me, many of the women said that the women in her family didn’t do anything to protect them from an aggressive partner. In fact, they may even have blamed her. This does nothing to encourage belief in a relationship of trust and respect, even with female practitioners.
Decades of research and documentation about the risks of continuing to drink during pregnancy often fail to trump the rationale that: “My Mum says she drank when she was pregnant with me, and it never did me any harm”. This disbelief in the risks of alcohol exposure in utero – and denial of the reality that so many people are adversely affected throughout their lives by Fetal Alcohol Spectrum Disorders (FASD) – have continued. They result from misleading media coverage; an ‘unhealthy relationship’ with alcohol in Scotland; professional reluctance to openly discuss drinking and pregnancy; and individual wishful thinking.
What if the pregnancy was unplanned/unintended/accidental? In my experience, a surprising number of women with an active sex life – even those who don’t want to become pregnant – do not use contraception. I spent time recently with a 16-year-old who was trying very hard NOT to admit she was pregnant. She was still going out with her friends every weekend and drinking quite a bit. I asked her why she was still doing that, and her answer was simultaneously understandable and shocking: “If I say I’m not drinking, then the first thing they will ask is: ‘Are you pregnant’?” Her own fears led to denial, preventing her from taking the health of herself and her baby fully into account. Imagine how isolated and lonely she felt.
This is only one side of an old story. In my forthcoming report, I will also explore why women in the upper half of the socioeconomic spectrum continue drinking during pregnancy. In fact, recent research suggests they are more likely to do so than those from more deprived socioeconomic backgrounds.
Silence about drinking and pregnancy is not helpful. Yet, anyone who has worked in a busy practice or clinic knows how difficult it can be to ask sensitive questions and discuss potentially uncomfortable topics when privacy may be challenging.
We are all human and how we ask any questions on any topic depends upon our comfort level. In my opinion, hesitation about alcohol discussions come more from the health professional than from the patient based on their own perception of how the conversation will go. If a woman is feeling guilty about her drinking, then she may be very sensitive to any questions about alcohol. She may be inclined to feel singled out or concerned she will be treated judgmentally. On the other hand, if alcohol questions are, and are understood to be, routine, then the tension around them usually dissipates. As a starting point, it’s simple to say: “Oh, it’s just one of the questions we ask everyone.”.
There is some truth in the maxim: “It’s not what you ask, it’s the way you ask it”. The onus is on us to think about how we word our questions and frame our conversations. How patients see us is a complex mix of past experiences and present expectations. That’s understandable, isn’t it? We’re human too.
As I write this, I am remembering a particularly severe hospital matron who would come into my ward and ask me a question. I knew the answer she wanted. I also knew that the answer she wanted was far from what I’d actually done or how I had behaved, especially on a very busy day. Did I always give the honest answer or was the pressure of her eagle-eyed judgement enough to make me fudge it? What do you think?
Sometimes, instead of pressing too hard or spending time trying to guess why a patient is taking her time to answer our questions, we just need to wait and listen. Creating an encouraging atmosphere of trust and respect is more likely to lead to a candid and meaningful conversation. These are the conversations that create the foundation for our advice and assistance.
YOUR reactions and suggestions are welcome at HPBL@qnis.org.uk or @HPBL_Scot
Read the third blog here