Alcohol use during pregnancy in Canada: how policy moments can create opportunities for promoting women's health.

Poole, Nancy ; Greaves, Lorraine

The federal, provincial and territorial governments endorsed new low-risk drinking guidelines for the Canadian population in November 2011. (1) This policy acknowledges that low-risk drinking guidelines are best approached through a sex/gender lens. This means that the recommended number of drinks per week that constitute low risk for women are different (and lower) than those recommended for men. These important recommendations came about after deliberations by the National Alcohol Strategy Advisory Committee that took into account research indicating that females metabolize alcohol differently than males, and that less alcohol would have equal or more effect on women's bodies than on men's. (2) Furthermore, with an understanding of the risks associated with alcohol consumption to a fetus and infant, these guidelines reinforce that pregnancy and breastfeeding are also identified as periods in women's lives when it is safest to not drink at all.

Nevertheless, in June 2012, a headline appeared in Canadian national media stating, "moderate drinking in pregnancy not cause for alarm." (3) This claim was based on a study by Danish researchers who found that adverse neuropsychological effects measured in children five years of age were not associated with moderate alcohol use in pregnancy. (4) At least once a year, a study on alcohol and pregnancy such as this one receives widespread media attention, leading to public uncertainty about the effects of drinking in pregnancy. It also creates additional challenges for those working on women's health promotion and specifically, the prevention of Fetal Alcohol Spectrum Disorder. In these instances, clear public health messaging grounded in supportive alcohol guidelines policy is urgently required.

The new low-risk drinking guidelines were announced in 2011. Though available, they are not yet well disseminated. These guidelines use differential definitions of at-risk drinking for women and

men: when applied, the size and scope of women's problem drinking in Canada is dramatically increased. Indeed, when the new guidelines are applied, the prevalence of high-risk drinking by women is heightened by 20% (from 34% to 53% by women aged 25 to 34 in reanalysis of CCHS survey data). (5,6) The use of these differential definitions of risky drinking for women illuminates a serious issue and a need for greater attention to prevention and health promotion for women drinkers, as well as more focus on clearly messaging and addressing the risks associated with alcohol consumption during pregnancy.

The introduction of these new guidelines has presented a critical policy moment in Canada, providing a valuable opportunity for action on the health promotion front. A comparable opportunity occurred in 2004-5 leading up to the 2010 Olympic games, when the Government of British Columbia developed a broad intersectoral health promotion initiative called ActNow. This initiative was an innovative and ambitious intersectoral approach to prevention and health promotion aimed at encouraging coordinated collaborative activity among government ministries and sectors. (7) Among its several components and streams, ActNow had a focus on the reduction of alcohol use during pregnancy called Healthy Choices in Pregnancy (HCIP).

The approach employed by HCIP signalled a dramatic shift in thinking about how to address alcohol use during pregnancy. Rather than focusing on the development and dissemination of information about the risks of alcohol use in pregnancy targeted at women directly, HCIP aimed its resources at providers. The goal was to facilitate proactive, multidisciplinary knowledge translation on pregnancy, alcohol and the related determinants of health. Health care and other service providers were encouraged to create a welcoming and effective support system for women and their families. Collaboration across a range of groups, professions and services was encouraged. Researchers, health system planners, service providers, policy-makers, and women themselves worked collaboratively on the initiative, as a key mechanism for enacting HCIP. In shifting from individual to systemic change, HCIP created a shift in attitude and focus from blaming individual women for drinking during pregnancy, to creating systemic change and action based on effective and supportive approaches to reducing alcohol use during pregnancy.

To this end, two key frameworks were introduced in HCIP: 1) a women-centred framework and 2) a harm-reduction framework. The women-centred framework emphasized the range of issues and determinants affecting women's health and encouraged the uptake of a respectful and gendered approach to women and alcohol use during pregnancy. (8) This framework also replaced fetus-centred frameworks that typically ignore pregnant women as worthy of health promotion and enhancement in their own right, and tend to focus solely on fetal or infant health. Additionally, a women-centred approach implicitly and explicitly replaced victim blaming and punitive, shaming attitudes and practices aimed at pregnant women who use alcohol. (9,10)

A harm-reduction framework was also introduced in the HCIP program, which valued and promoted a wide range of behaviours and initiatives aimed at mitigating the effects of alcohol use. For example, while abstinence from alcohol during pregnancy is the ideal, for some women, reduction in alcohol use is an improvement that can more realistically be achieved. Collateral improvements in nutrition, vitamin intake, personal safety, and food and housing security can also be part of an overall harm-reducing framework. (11) When these kinds of measures are part of health promotion regarding alcohol use during pregnancy, overall health for women and their fetuses can be improved even when alcohol use continues.

In the HCIP initiative, the goal was to increase by 50% the number of women counseled about alcohol use in pregnancy by educating a wide range of practitioners to confidently and effectively discuss with women - in new, supportive, and respectful ways - the topic of drinking. In order to promote this and other goals, four levels of actors were mobilized to act in concert. First, there was an explicit governmental priority on the issue, clearly articulated and part of a well-funded initiative. Second, there was concomitant structural support within the Health Authorities in BC to implement the provincial priority. Third, there were resource experts to develop and support a participatory, empowering, and equity-oriented approach to carrying out HCIP. Finally, there were key community-based organizers and learners across the province keen on skill building in the interests of women's health promotion.

In the end, the policy moment created by the Olympics was used to advance understanding and action on three aspects of women's health: 1) reducing alcohol use during pregnancy, 2) inculcating a gendered, women-specific approach to health promotion, and 3) generating and engaging a network of players and agents across BC through a variety of activities, training, and knowledge translation efforts.

Seven years later, we have another such opportunity with the announcement of clear, sex-specific and gendered, evidence-based advice in the form of low-risk drinking guidelines. How can women's health promotion regarding alcohol make use of this new information to regenerate and refocus itself? We suggest that the lessons from the HCIP program could inform ongoing efforts. We can capitalize on this shift in policy to bring the widest possible attention to the sex-specific effects of alcohol use, and the dramatically expanded size of the risky-drinking problem among women when these new guidelines are applied. However, in order to create effective change for women, we need to engage a range of groups, professions and services to collaborate to create systemic change, making a women-centred and harm-reduction informed approach the new standard. In addition, we need to coordinate an approach across the country, engaging a range of players. Most importantly, we can leverage the knowledge gained in BC to help pan-Canadian system planners and service providers effectively bring to women the message in the new guidelines about the risks of drinking during pregnancy - in the supportive and respectful ways pioneered in the Healthy Choices in Pregnancy Program leading up to the Olympics in 2010. This is an opportunity not to be missed.

Conflict of Interest: None to declare.

REFERENCES

(1.) Canadian Centre on Substance Abuse. Canada's Low-Risk Alcohol Drinking Guidelines, 2011. Available at: http://www.ccsa.ca/eng/priorities/alcohol/ canada-low-risk-alcohol-drinking-guidelines/pages/default.aspx (Accessed July 20, 2012).

(2.) Butt P, Beirness D, Cesa F, Gliksman L, Paradis C, Stockwell T. Alcohol and Health in Canada: A Summary of Evidence and Guidelines for Low-risk Drinking. Ottawa, ON: Canadian Centre on Substance Abuse, 2011.

(3.) CBC News. Moderate drinking in pregnancy not cause for alarm: 5 to 8 drinks weekly have no effect on child development study suggests, 2012. Available at: http://www.cbc.ca/news/health/story/2012/06/20/alcohol-pregnancy.html (Accessed July 20, 2012).

(4.) Kesmodel U, Bertrand J, Stovring H, Skarpness B, Denny C, Mortensen E, Lifestyle During Pregnancy Study Group. The effect of different alcohol drinking patterns in early to mid pregnancy on the child's intelligence, attention, and executive function. BJOG 2012;119(10):1180-90.

(5.) Bialystok L, Thomas G, Greaves L, Poole N, Dell C. Alcohol Use Among Women in Childbearing Years. Ottawa: Public Health Agency of Canada. In press.

(6.) Poole N, Thomas G, Grieves L. Alcohol Use by Girls and Young Women. Presented at Issues of Substance 2011: Transforming health promotion, prevention, treatment and recovery. [Conference] Vancouver, BC, November 7, 2011.

(7.) Public Health Agency of Canada. Mobilizing Intersectoral Action to Promote Health: The Case of ActNowBC in British Columbia, Canada, 2009. Available at: http://publications.gc.ca/site/eng/379869/publication.html (Accessed April 5, 2013).

(8.) Greaves L, Poole N, Cormier R. Fetal Alcohol Syndrome and Women's Health: Setting a Research Agenda. Vancouver, BC: British Columbia Centre of Excellence for Women's Health, 2002.

(9.) Poole N. Bringing a Women's Health Perspective to FASD Prevention. In Riley EP, Clarren S, Weinberg J, Jonsson E (Eds.), Fetal Alcohol Spectrum Disorder: Management and Policy Perspectives of FASD. Wenheim, Germany: Wiley-VHC Verlag GmbH & Co., 2010.

(10.) Greaves L, Poole N. Victimized or validated? Responses to substance-using pregnant women. Can Women's Studies J2005;24(1):87-92.

(11.) Poole N, Urquhart C, Talbot C. Women-Centred Harm Reduction, Gendering the National Framework Series (Vol. 4), in Gendering the National Framework. Vancouver: BC Centre of Excellence for Women's Health, 2010.

Received: October 17, 2012

Accepted: January 24, 2013

Nancy Poole, MA, Lorraine Greaves, PhD

Author Affiliations

British Columbia Centre of Excellence for Women's Health, Vancouver, BC

Correspondence: Nancy Poole, BCCEWH, E311, 4500 Oak Street, Box 48, Vancouver, BC V6H 3N1, Tel: 604-875-2633, Fax: 604-875-3716, E-mail: npoole@cw.bc.ca Table 1. Excerpt From Canada's Low-Risk Alcohol Drinking Guidelines Guideline 1 (Your limits) Reduce your long-term health risks by drinking no more than: * 10 drinks a week for women, with no more than 2 drinks a day most days * 15 drinks a week for men, with no more than 3 drinks a day most days Plan non-drinking days every week to avoid developing a habit. Guideline 2 (Special occasions) Reduce your risk of injury and harm by drinking no more than: * 3 drinks (for women) on any single occasion * 4 drinks (for men) on any single occasion. Plan to drink in a safe environment. Stay within the weekly limits outlined in Guideline 1. Guideline 3 (When zero's the limit) Do not drink when you are: * driving a vehicle or using machinery and tools * taking medicine or other drugs that interact with alcohol * doing any kind of dangerous physical activity * living with mental or physical health problems * living with alcohol dependence * pregnant or planning to be pregnant * responsible for the safety of others * making important decisions Guideline 4 (Pregnant? Zero is safest) If you are pregnant or planning to become pregnant, or about to breastfeed, the safest choice is to drink no alcohol at all.