Prevention of alcohol-related birth defects can focus at reducing AEP risk among non- pregnant women or at reducing or preventing alcohol use among pregnant women. Interventions can be universal (such as media campaigns and educational interventions) or targeted/indicated (such as BI) or cognitive behavioural therapy) (Barry et al., 2009).
Brief interventions are “those practices that aim to identify a real or potential alcohol problem and motivate an individual to do something about it” (Babor & Higgins-Biddle, 2001, p. 6). In combination with screening, BI is a way for health professionals to raise the question about patients’ alcohol consumption and support behaviour change for people who drink at hazardous or harmful levels (Babor & Higgins-Biddle, 2001). In primary care
settings, BI has demonstrated good effectiveness in reducing harmful and hazardous drinking (Gebara et al., 2013; Kaner et al., 2009), but for pregnant women the evidence is overall inconsistent (Gilinsky, Swanson & Power, 2011). A systematic review of randomized controlled trials (RCTs) only found four studies that fit the inclusion criteria. The overall conclusions of the review was that despite that psychological and educational interventions appeared to have some impact on reducing alcohol consumption, the paucity of studies along with high risk of bias within studies limit the possibility to draw conclusions about effectiveness of interventions (Stade et al., 2009).
Results from individual studies have shown promising results from various types of interventions in promoting abstinence or reducing alcohol use. For example, van der Wulp et al. (2014) found that women who received a computer-tailored feedback intervention were more likely to abstain from alcohol than women who received standard care (OR = 2.77, 95% CI 1.02–7.34) at six months follow-up. The intervention was also compared with health counselling with a midwife, where the intervention performed no better than the health counselling and there was no significant difference between standard care and health counselling. The computer-tailored intervention significantly reduced alcohol use among women who consumed one standard deviation below the mean before pregnancy (p < 0.001), but not among women who drank above the mean (p = 0.57). O’Connor and Whaley (2007) found that a single-session of BI was associated with significantly higher odds of abstinence, compared to women who received assessment only (OR = 5.39, 95% CI 1.59–18.25, p < 0.05). Among women who prior to the enrolment in the study (around 18 weeks) drank two standard drinks or more per occasion and received the intervention had better birth outcomes (for example higher birth weight) than the control group (O’Connor & Whaley, 2007).
Although research on universal interventions (educational and public health interventions) is limited, a review of studies suggested that these types of interventions can increase awareness of risks with drinking alcohol during pregnancy (Crawford-Williams et al., 2015a). Specifically, a study of a campaign targeting American Indian women found that women of childbearing age perceived an increase in knowledge of FAS (91.6%) and risks with drinking alcohol when pregnant (93.3%). The majority (71.8%) of the 119 women included in the study reported that they had reduced their drinking as a result of the campaign (Hanson, Winberg & Elliot, 2012). An American study of a multimedia campaign targeting pregnant women found that women exposed to the intervention were
more likely to have talked to at least one friend about alcohol and pregnancy (58.3% versus 49.4%, p = 0.05) (Lowe et al., 2010). Yet the design of messages targeting pregnant women may influence their response to the information. An experimental study of 354 pregnant and non-pregnant Australian women showed that messages with a threat appeal (focusing on the risks from alcohol exposure) and a combined message of threat appeal and self-efficacy (focusing on behaviour change in the context of women’s social situations and peer support) was significantly associated with women’s intention and confidence to abstain from or reduce their alcohol during pregnancy, compared to the control condition (France et al., 2014). A more recently published RCT study including 564 Swedish women indicated that simply providing written information can encourage women not to drink. Women who received an information leaflet prior to the first antenatal visit were more than twice as likely to abstain, compared to women in the control group (OR = 2.6, 95% CI: 1.3–5.1, p = 0.005) (Bortes et al., 2015). Another RCT including 161 pregnant women in Australia found that an intervention of an information booklet with mocktail (non-alcoholic cocktails) recipes significantly improved attitudes and knowledge of drinking during pregnancy. However, compared to the control group, who received standard antenatal care only, there was no significant difference in abstinence (RR = 1.3, 95% CI: .97–1.75, p = 0.077) (Crawford-Williams et al., 2016).
Research has also suggested that certain factors influence the success of interventions, such as partner support. A study of 304 women and their partners in the USA showed that a single-session BI was more effective on women who consumed alcohol at higher levels when they enrolled in the study, and whose partner took part in the intervention (Chang et al., 2005). Another study of 526 couples in Sweden found that while there was no difference in abstinence rates between the intervention group and the control group, psycho-social support from partners was higher in the interventions group. Women who received the intervention, a dialogue with the midwife from a life cycle perspective on alcohol which also included history of alcoholism in the family, were significantly more likely to report that their partner always offered them non-alcoholic alternatives (OR = 2.13, 95% CI 1.29–3.51) (Högberg, Spak & Larsson, 2015).
Overall, the literature is not conclusive on effective interventions for pregnant women. It has been suggested that women who continue to drink during pregnancy may need more intense interventions, especially women who drink at higher levels (Gilinsky, Swanson & Power, 2011). This may be one reason why remote interventions have been effective on
women who drink at lower levels (van der Wulp et al., 2014) and face-to-face BI has shown positive effects on women who drink at higher levels (Chang et al., 2005; Marais et al., 2010). One interesting observation is that several studies have not found significant effects of interventions, due reductions in intake also in the control group. In some studies, the control group received assessment only, meaning they were screened for alcohol use (Osterman & Dyehouse, 2012; Tzilos et al., 2011). It is known that screening can influence behaviour change (McCambridge & Kypri, 2011), which emphasises the importance of screening and brief intervention in antenatal care, as recommended in the WHO ‘Guidelines for the identification and management of substance use and substance misuse during pregnancy’ (WHO, 2014c).
Qualitative work on the implementation of BI in antenatal care in Scotland has shown that many midwives felt they did not have enough experience through practice of using BI, due to most women reporting not drinking alcohol. Midwives believed the first appointment to be the best time to do screening and deliver BI, even though they were concerned about potential negative effects on their relationship with the woman. Gaining trust of the woman at the initial meeting was perceived as important and discussing alcohol was mentioned as a possible barrier to establish a good relationship. Midwives listed time constraint and heavy work load as a barrier to alcohol brief interventions, as alcohol therefore was not prioritised. Conversion of alcoholic drinks into units was also mentioned as a barrier (Doi, Cheyne & Jepson, 2014), which is consistent with barriers mentioned by women for accurately report their alcohol consumption (Muggli et al., 2015).
In summary, whilst the evidence for effective interventions to prevent alcohol exposure during pregnancy is limited (Crawford-Williams et al., 2015a; Gilinsky, Swanson & Power, 2011; Stade et al., 2009) some approaches appear to be successful. Focusing on involving the pregnant woman’s partner and considering the mode of delivery (face-to-face or computer-based) may be important for the intervention to be effective. However, interventions may have different impact on women drinking at high levels, compared to those consuming small amounts.