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Polish Public Health Response to Drinking during Pregnancy
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Due to the risks it poses to a child’s health, drinking alcohol during pregnancy is a serious problem that the public health sector is struggling to deal with. The reasons why women who do not have alcohol problems do not give up drinking alcohol completely during pregnancy are still poorly understood. And the knowledge available about them does not translate into communication strategies in Poland. The analysis of standards and examples of good practice allows to formulate proposals for improving the quality and effectiveness of social campaigns addressed to the general population and women of childbearing age in order to reduce the risk associated with the prenatal exposure to alcohol.

fetal alcohol spectrum disorders (FASD) women’s perspective public health response
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    1. Introduction

    Drinking alcohol is one of the health behaviors about which every person makes countless decisions throughout their life. When deciding whether to drink or not to drink, what, in what amounts, when, in what company, etc., people rely on their previous experiences, behaviors observed in other people, normative beliefs, knowledge about the consequences [1][2]. Each time, of great importance are factors related to the context in which the decision is made, including the temporary emotional state (e.g., [3][4][5][6]). In many cases, drinking alcohol creates a conflict between what people can and want to do and what they should do for health, social or legal reasons. Dilemmas usually involve the effects of alcohol on the drinker’s own health.
    However, for women who are pregnant or planning to become pregnant, the key issue is the effects of alcohol not on her own, but on the health of the baby to be born [7]. Consumption of alcohol during pregnancy can result in a number of adverse consequences for the fetus, including congenital malformations and behavioral, cognitive and adaptive deficits. Animal studies have shown that each stage of embryonic development is susceptible to the teratogenic effects of alcohol [8]. Prenatal exposure to alcohol is a major cause of brain damage and developmental delay known as Fetal Alcohol Spectrum Disorder (FASD).
    How women make decisions about drinking alcohol during pregnancy is not fully understood. It is known that most women (70–87%) give up alcohol as soon as they find out that they are pregnant [9][10]. It is also known that for women addicted to alcohol, who, for instance, in USA constitute about 5% of the pregnant population [11], making such a decision is too difficult. But what about women that are not addicted, know they are pregnant, and still drink alcohol as before, or only limit the frequency and/or amount of alcohol consumption?

    2. Understanding Women’s Reasoning about Alcohol Use during Pregnancy

    The literature (e.g., [12][13][14][15][16]) indicates many different factors that increase the risk of drinking alcohol during pregnancy, including: lack of knowledge, medical conditions (e.g., addiction, mental disorders) or contextual factors (e.g., trauma, domestic violence, partner’s influence). However, from the perspective of public health responses to the challenges arising from the fact that the prevalence of alcohol use during pregnancy is rather not diminishing [17], better understanding of women’s reasoning about alcohol use in pregnancy is needed. Gaining insight into women’s beliefs and understanding of risk associated with alcohol use during pregnancy is necessary to inform targeted prevention strategies.
    Women’s perception of the risk associated with drinking alcohol during pregnancy vary greatly due to inconsistent information that reaches them from various sources, including government guidelines, health organizations, media, family and friends. Moreover, women rarely receive individualized advice from health professionals [18][19]. The information on the impact of alcohol use on a fetus is often misunderstood by women [20][21]. Although smoking during pregnancy is generally considered to be a risk-taking behavior, moderate drinking of alcohol, in small amounts, is perceived as acceptable [21][22]. Alcohol use by a partner, his encouragement of light drinking or support in handling the struggles associated with reducing alcohol intake, is a significant factor determining alcohol use in pregnancy [19][22][23][24]. Women who continue to drink during pregnancy usually do so in social contexts of festive occasions [24]. As shown in the research comparing practices and attitudes towards alcohol use during pregnancy in England and Sweden “wider social norms and attitudes, interlinked within the policy context, may influence whether pregnant women drink alcohol” [24]. It can also be assumed that the differences found in the UK and Swiss studies in the importance of reducing the risk of drinking alcohol during pregnancy ascribed to health professionals reflect cultural (national) differences. In Switzerland health professionals were rarely mentioned as important resources of support [23] while in UK support from health services played an important role in shaping women’s behavior [22].

    3. Exploration of Polish Women’s Reasoning about Alcohol and Pregnancy

    Interesting qualitative research among Polish women, commissioned by the State Agency for Prevention of Alcohol Related Problems (PARPA), was conducted by the 4P Research Company [25]. It aimed to explore women’s knowledge, attitudes and believes towards alcohol consumption during pregnancy. Participants of focus group interviews (FGI) were recruited in Warsaw (capital city) and Płock (smaller town) from the general population of women (with various education, occupation and parenting status) of childbearing age (24–39 years old). Half of respondents was pregnant and half not pregnant, but not ruling out the possibility of becoming mothers in the foreseeable future. All non-pregnant women were not abstainers currently and pregnant women were not abstainers before pregnancy. Half of the respondents rejected alcohol use during pregnancy while the others did not (thought that some alcohol during pregnancy is acceptable). In order to facilitate open conversation the composition of each focus group was based on participants pregnancy status (yes/no) and attitudes toward alcohol use during pregnancy (not acceptable/acceptable).
    Key findings:
    • Being a good mother is equally important for all women, regardless of their attitudes and behaviors regarding alcohol consumption during pregnancy. Women accepting (small amounts of lighter) alcohol during pregnancy seem just as committed (future and current) mothers as those who completely reject drinking alcohol during pregnancy. They associate pregnancy with healthy lifestyle, family, time of change and expectation.
    • Locus of control over the pregnancy (me versus my doctor).
      • “First of all, do no harm”—characterize the dominating approach toward care of the unborn child and pregnancy of women definitely rejecting alcohol during pregnancy. Not surprisingly, this harm avoidance perspective includes alcohol abstinence and makes the mother the key health agent.
      • “Medical” factors are crucial—women accepting small amounts of alcohol during pregnancy underlined the importance of good medical care (regular visits to the doctor and adherence to recommendations, ultrasound examination, etc.). This suggests a shift in the responsibility for the outcome of pregnancy from the mother to the medical staff.
    • No evidence of harmful effects of moderate drinking has different meaning for women accepting or rejecting small amounts of alcohol during pregnancy. In general, an opinion prevails that there is no clear evidence that small amounts of light alcohol are harmful to the foetus, so:
      • For women who accept drinking alcohol during pregnancy, this means that there is no evidence of harmful effects and you can drink (a little).
      • For women who do not accept drinking alcohol during pregnancy, this means that there is no evidence of harmlessness, so you can’t drink.
    • “FAS (fetal alcohol syndrome) occurs in pathological families”. Among women who accept drinking during pregnancy, there is a strong emotional distancing from the threat of FAS by identifying it (only) with the children of mothers who are alcoholics, drink compulsively or get drunk regularly. This seems to reflect media “bombshells” (for example about “drunk newborns”).
    • “I wouldn’t tell the doctor” for fear of his/her reaction. Women think that it is easier to talk with a friend or write in internet about alcohol and pregnancy than to talk openly with a doctor. They expect criticism, e.g., “Oh, what have you done!?” or disregard, as one respondent said: “It’s if I asked about the FAS, she [the doctor] would say to me: “Madam, madam … —she would look at me—No, this does not apply to you.” Psychologist and fortune teller in one”. It should be noted that there were also respondents who, although did not deny the general opinion about doctors, emphasized that they are extremely lucky because they can talk to their doctor about everything.
    • Mental rationalizations among women who accept alcohol consumption or drink alcohol during pregnancy to convince or reassure themselves in respect of threats to the child related to prenatal alcohol exposure:
      • “Pregnancy is not a disease”—this very well known in Poland slogan is interpreted as encouragement to maintain in pregnancy the same lifestyle (including alcohol use in moderate amounts) as before.
      • There are other, not avoidable teratogens-e.g., air pollution, some medicines with unknown impact on fetus.
      • Alcohol abstinence during pregnancy is a „new-fashioned” exaggeration and dictatorship of bans and orders
      • Pregnant women are constantly threatened and criticized—„No matter what I do, it will be considered as wrong”
      • Medical recommendations (in general) are not stable in time and probably those regarding alcohol use in pregnancy would be changed soon.
    This unique in Poland research revealed many different opinions, myths, misunderstandings and approaches toward alcohol use during pregnancy. It made clear that in spite of several efforts to disseminate information on FAS/FASD in the public space, women’s knowledge is fragmentary and imprecise and therefore, they are not sure how to behave.

    4. Opinions and Expectations about Information Campaigns on Drinking Alcohol and Pregnancy

    Voices of women participating in the focus group interviews [25] indicated that communication strategies addressing women who do not reject drinking or drink moderately during pregnancy are needed. Especially for women before and during their first pregnancy, when the level of anxiety and uncertainty is higher than during the next one. These women care about the health of their children, and when it comes to alcohol, they are not completely sure if they are doing the right thing. The following guidelines for communication planning follow from the research:
    • Avoid criticizing or stigmatizing alcohol consumption during pregnancy, because pregnant women/mothers feel beleaguered by social criticism, so they often respond to it with some kind of defiance resulting from helplessness.
    • Avoid excessive “scaring”—because pregnant women/mothers feel “constantly threatened” and scaring can give effects opposite to the intentions and cause rejection of threatening information.
    • What may have the potential is showing real life stories (testimonials), which document that FASD can happen in a “normal” family, where the mother is not an alcoholic, but drank moderately during pregnancy or before knowing she is pregnant. Presentation of a case-a child with FASD would have high emotional load and therefore may have a tremendous influence on one’s attitude towards drinking during pregnancy. Due to emotionality and rooting in everyday life, this communication direction should also be effective in case of people who rely rather on tradition and life experience than “science”.
    • Since there is no evidence of the harmful effects of exposure to small amounts of alcohol on the fetus, the campaigns should reveal the irrationality of the applied mental strategies (e.g., “If you saw someone crossing the street outside the crosswalk and not being run over, does it mean that such crossing is not associated with risk?”).
    • The message should be simple, clear and not leaving any room for different interpretations. As a good example may serve campaigns on drink driving, in which nobody discuss that a small amount of alcohol in the blood is acceptable. Similarly, in reference to pregnancy any doubts concerning different harmfulness of prenatal alcohol exposure due to individual differences between woman or the stage of pregnancy should be omitted.
    • The best remembered are “strong” messages, exemplified by social campaigns against cigarette smoking during pregnancy, as cited by one of the respondents: “Do not turn your belly into a gas chamber”.
    • Communication channels that may have potential are for example blogs (mothers-bloggers are perceived as close and reliable). Besides, also midwives could be educators for women (perceived as being nearer to “real life” and thus more reliable than doctors).

    5. Public Awareness Campaigns on FAS/FASD in Poland

    Probably the most influential, especially among local stakeholders, has been “Ciąża bez alkoholu” [“Pregnancy without alcohol”] initiated by PARPA (State Agency for Prevention of Alcohol-Related Problems) in 2007. It managed to engage various institutions, local authorities and NGOs and significantly contributed to the spread of awareness of the harmful effect of alcohol consumption during pregnancy on the health of an unborn child. The campaign’s slogan “I don’t drink to his health” referred to the most common Polish toast: “To health!”. By definition, the campaign was positive, did not stigmatize pregnant women and did not threaten with damages resulting from PAE. Instead, it showed a somewhat schematic, idealized image of a happy family that had little to do with real-life stories. Currently, the educational website with the same title (Pregnancy without alcohol) is available for general population and professionals (www.ciazabezalkoholu.pl, accessed on 16 February 2022).

    It may be concluded that the visibility of FASD prevention campaigns is very limited. Most women of childbearing age have never seen such activities at all. Although there are some examples of campaigns clearly avoiding scaring, criticizing or stigmatizing alcohol consumption during pregnancy, but there are also examples of activities based on the opposite approach. In all campaigns, the messages are rather simple and clear (“do not drink alcohol during pregnancy”). The emotional load of campaigns using threatening strategies is much stronger than in “positive” campaigns, but still, most of the addressees do not identify themselves with it, thinking that it is rather directed to people addicted to alcohol. There are no campaigns using testimonials or referring to the mental strategies used to justify moderate drinking during pregnancy.

    6. (Dis) Accordance of Polish Public Awareness Campaigns on FAS/FASD with Quality Standards

    International Standards on Drug Use Prevention [26] provide characteristics of media campaigns deemed to be associated with efficacy and/or effectiveness (pp. 33–34):
    • “They precisely identify the target group of the campaign.
    • They are based on a solid theoretical basis.
    • The messages employed are designed on the basis of strong formative research.
    • They strongly connect with other existing drug prevention programmes in the home, school and community.
    • They achieve adequate exposure of the target group for a long period of time.
    • They are evaluated systematically.
    • They target parents, as this also appears to have an independent effect on the children.
    • They are aimed at changing cultural norms about substance use, educating about the consequences of substance use and/or suggesting strategies to resist substance use.”
    Unfortunately, none of the Polish campaigns aimed at reducing the risk of drinking alcohol during pregnancy and FASD meets the above criteria. In contrary, most of the campaigns are badly designed (without testing of their concepts) and implemented with limited resource (if not sponsored by the alcohol industry). Any of them has been evaluated and most of them passed unnoticed due to insufficient coverage, limited forms and implementation time. As shown by [27] achieving adequate exposure (it was 10 or more times of hearing the message) is necessary to improve FAS prevention knowledge among the target group. With lower exposure, the massage might be misinterpreted and counterproductive.
    It may be proposed to differentiate the FASD prevention messages addressing three groups of women:
    • The key message to women who do not accept even moderate alcohol use during pregnancy should strengthen their attitude (saying: Yes, you are right, keep doing) and, eventually promoting abstinence (or moderate drinking) when planning the pregnancy and/or encouraging use of effective contraceptive measures to avoid unplanned pregnancy.
    • In case of women accepting moderate alcohol use during pregnancy, probably effective would be warning about the health hazard associated with exposing the fetus to moderate doses of alcohol (Like: Is the momentary pleasure of drinking a glass of wine worth worrying about your child’s health for the rest of your life?).
    • Women with alcohol related problems may probably benefit from a campaign based on the CHOICES model [28][29][30] underlying that it’s never too late to stop/moderate your drinking (Although sooner is better) or to prevent getting pregnant. (Just because you have an alcohol problem doesn’t mean you can’t be a good mother. Take the first step and seek support).
    The Polish women’s expectations (presented above) suggest at least two theoretical frameworks which might be useful in campaigns planning. First is the exemplification theory [31][32], stating that messages that use concrete, iconic and emotionally arousing exemplars are easily accessed and therefore people tend to rely upon them when making behavioral decisions. And women are especially vulnerable to this kind of messages [33]. Probably the strongest preventive effect would have “testimonials” of biological mothers of children with FASD like ones presented by women from the NOFAS Circle of Hope, who share their stories on the YouTube (https://fasdunited.org/stamp-out-stigma/, accessed on 16 February 2022). Unfortunately, there is no organization in Poland that brings together biological mothers of children with FASD. The fear of stigmatization and social rejection for drinking alcohol during pregnancy is still too strong. A leader as brave, strong and determined to help women who need support to cope with the guilt and grief of drinking alcohol during pregnancy as Kattie Mitchel, the Vice President of the National Organization on Fetal Alcohol Syndrome (NOFAS), has not yet emerged among Polish mothers.

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      Okulicz-Kozaryn, K. Polish Public Health Response to Drinking during Pregnancy. Encyclopedia. Available online: https://encyclopedia.pub/entry/21616 (accessed on 06 February 2023).
      Okulicz-Kozaryn K. Polish Public Health Response to Drinking during Pregnancy. Encyclopedia. Available at: https://encyclopedia.pub/entry/21616. Accessed February 06, 2023.
      Okulicz-Kozaryn, Katarzyna. "Polish Public Health Response to Drinking during Pregnancy," Encyclopedia, https://encyclopedia.pub/entry/21616 (accessed February 06, 2023).
      Okulicz-Kozaryn, K. (2022, April 12). Polish Public Health Response to Drinking during Pregnancy. In Encyclopedia. https://encyclopedia.pub/entry/21616
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