Public health campaigns that recommend abstinence from alcohol during pregnancy have been, for the most part, successful. There are, however, some women for whom the "Just Say No" approach to drinking during pregnancy does not resonate. In an effort to better understand this anomaly, a study in the August issue of Alcoholism: Clinical & Experimental Research (ACER) closely examined the exposure and response to health warnings among two groups considered most at-risk for Fetal Alcohol Syndrome (FAS): American Indians and African Americans.
"We wanted to look at how some women interpret the messages they’re receiving," said Lee Ann Kaskutas, a research scientist with the Alcohol Research Group at Berkeley and author of the study. "We wanted to know if they understand and believe the health warnings. We wanted to discover what misconceptions women might have about the risk of drinking during pregnancy, what drinking habits they might have during pregnancy, and we also wanted to look very carefully at their drink size." The ACER paper is part of the larger Developing Effective Educational Resources (DEER) project, which is designed to closely examine how warnings about drinking during pregnancy reach and affect women whose children are believed to be most at-risk for FAS.
As many people are aware, heavy drinking during pregnancy can cause FAS, which is the largest preventable cause of birth defects and mental retardation in the United States. Lighter drinking during pregnancy can lead to Fetal Alcohol Effects (FAE), such as low birthweight, slower postnatal growth, and even spontaneous abortion. The Centers for Disease Control and Prevention (CDC) has found that about 15 percent of women consume alcohol during their pregnancies, and 2.1 percent consume alcohol frequently. The CDC also found that both alcohol use and frequent use of alcohol during pregnancy - after a decrease in the early 1990s - has lately increased. Alcohol use was 22.5% in 1988, dropped to 9.5 percent in 1992, then climbed up to 15.3 percent in 1995; frequent use was 3.9 percent in 1988, dropped to 0.9 percent in 1991, then climbed up to 3.5 percent in 1995.
Kaskutas said that some estimates have placed the cost of treating just some of the FAS disorders that occur at more than $321 million per year. An alternative method of estimation is to look at the cost of taking care of mentally retarded people in one year (approximately $11.7 billion), multiplying that by 11 percent (believed to be due to FAS), for an amount that exceeds one and one quarter billion dollars per year. Some ethnic groups seem to be more at-risk than others, and Kaskutas’ study looked at the two groups with the highest rates of FAS: American Indians (2.97 per 1,000 births) and Blacks (0.6). Other rates are as follows: whites (0.09 per 1,000 births)), Hispanics (0.08), and Asians (0.03).
"Health campaigns that are directed at pregnant women have had a long reach," observed Kaskutas, "and most women are abstaining just like the messages have said to do." She said that the same health messages are also reaching those women considered most at-risk. "Most of these women have seen the warning label on alcohol containers, most have seen an advertisement about drinking while pregnant, more than half have seen a sign at a liquor store or restaurant, and the vast majority said they have had a conversation on the topic. Furthermore, all but 10 percent said that they understood and believed the messages." Then why is there still a problem?
"Those women who continued to drink while pregnant," explained Kaskutas, "were more likely to say that these messages made them feel negatively toward themselves. This can, in turn, contribute to a negative self-esteem spiral of drinking and lack of proper care during pregnancy."
"Health campaigns may need to be part of a larger attempt to change social norms," added Ernestine Vanderveen, director of the National Institute on Alcohol Abuse and Alcoholism’s Alcohol Research Centers Program, "such as consumption behavior that involves harmful substances like alcohol, nicotine and caffeine." One of the obstacles that researchers and public health officials still face, she noted, is a basic lack of understanding of human behavior. "We still don’t fully know how one’s behavior relates to one’s state of health and well-being, nor do we really understand the difference between ‘health-enhancing’ and ‘health-compromising’ behaviors. That’s why," she continued, "we really don’t know a lot about women’s drinking."
Vanderveen said that one of the real strengths of Kaskutas’ study was that it was conducted in the field. "This study has relevance because it attempts to get at information that is very difficult to extract," she said. "In general, we probably need more work in terms of finding out from real people what their behaviors are, and how those relate to their health and well-being." Vanderveen wants to see the DEER project’s methodology refined, expanded to a larger study group and geographic distribution, and then replicated so that it can address what she called "serious health disparities in the nation."
A large part of the problem, said Kaskutas, is due to misconceptions both about and among the study populations. "I want to address this issue of ethnicity," she said. "When you consider the income of these women, then the higher rate for FAS that we see by ethnicity disappears. So some of this disease is about poverty. And the women in my study were poor … very poor, inner-city women." Kaskutas said she chose to focus on urban women because most of the research on American Indians has been carried out on reservations, and the few studies on Black urban women have not included American Indian urban women.
"There are also some misconceptions among the women most in need of accurate information," she continued. "Fewer than one in five of these women realize that it helps to cut down any time during pregnancy; African Americans and heavier drinkers are the most likely to feel this way. We also found that some women think certain beverages are safer than others. For example, wine drinkers think wine is safer, beer drinkers think beer is safer. Some women think that ‘if it burns going down,’ then it’s bad for the baby, otherwise it’s not. In addition, the women who drank more often also tended to have larger drinks. A woman may tell the nurse she just has one drink a day, but maybe her single drink was really a 40-ounce bottle of malt liquor." Kaskutas noted that, within the alcohol studies field, one 12-ounce can of beer equals one standard drink, as does one four-ounce glass of wine, and one one-ounce shot of whiskey. Fortified wine has a higher alcohol content than wine; malt liquor has a higher alcohol content than beer.
"This study tells us a number of things," said Kaskutas, "but probably the two most important findings have to do with message content and determination of risk. Current health messages call for abstention from alcohol during pregnancy. This is great if it works, but the reality is that the ones who continue drinking are the heavier drinkers. They ignore the abstention message. For these women, we need to make it clear that it does help to cut down at any time during the pregnancy. The second finding concerns drink size. We have got to pay attention to drink size when we study drinking during pregnancy. We also need to tell pregnant women about standard drink sizes, so they can’t deceive themselves than a 40-ounce bottle of malt liquor is one drink."
"All women want their babies to be healthy," said Kaskutas, "even the ones who continue drinking during pregnancy."
Funding for this Addiction Science Made Easy project is provided by the Addiction Technology Transfer Center National Office, under the cooperative agreement from the Center for Substance Abuse Treatment of SAMHSA.
Articles were written based on the following published research:
Kaskutas, L.A. (2000, August). Understanding drinking during pregnancy among urban American Indians and African Americans: Health messages, risk beliefs, and how we measure consumption. Alcoholism: Clinical and Experimental Research, 24(8), 1241-1250.