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Pregnancy Care Guidelines

13 Alcohol

Alcohol consumption increases the risk of injury in the short-term and chronic disease in the longer term. Drinking in pregnancy can have significant effects on fetal development.

Work is currently underway to update the Australian Guidelines to Reduce Health Risks from Drinking Alcohol (Alcohol Guidelines) and revised guidelines are expected to be available early in 2020. Following this review process, the content of this chapter will be updated. Further information on the review of the Alcohol Guidelines can be accessed at NHMRC.

Experts in the alcohol field have worked with the Australian Government to prepare the following resources:

13.1 Background

The information in this section, including the consensus-based recommendation, is based on Guideline 4 in NHMRC (2009) Australian Guidelines to Reduce Health Risks from Drinking Alcohol (under review). Canberra: National Health and Medical Research Council. Literature on prevalence of alcohol consumption and associated risks during pregnancy published subsequent to the NHMRC guidelines has not been reviewed.

13.1.1 Alcohol consumption among pregnant women in Australia

The National Drug Survey reported that in Australia in 2013 (AIHW 2014):

  • more than half (56%) had consumed alcohol during their pregnancy, and while a large proportion of these women stopped drinking alcohol once they find out that they were pregnant, one-quarter (26%) continued to drink once they knew they were pregnant
  • about 3 in 4 (78%) pregnant women who consumed alcohol while pregnant drank monthly or less, and 17.0% drank 2–4 times a month
  • most (96%) usually consumed 1–2 standard drinks
  • only 1.4% had consumed 6 or more standard drinks on at least one occasion during their pregnancy.

13.1.2 Risks associated with alcohol consumption in pregnancy

High-level and/or frequent intake of alcohol in pregnancy increases the risk of miscarriage, stillbirth and premature birth (O’Leary 2004).

Alcohol crosses the placenta and nearly equal concentrations in the mother and fetus can be attained. Exposure of the fetus to alcohol may result in a spectrum of adverse effects, referred to collectively as fetal alcohol spectrum disorders (FASD). Of these, fetal alcohol syndrome (FAS) has been described in children exposed to high levels of alcohol in utero as a result of either chronic or intermittent maternal alcohol use (Lemoine et al 1968; Jones et al 1973; Hoyme et al 2005; Astley & Clarren 2000). These children have characteristic facial abnormalities (and often a range of other birth defects), impaired growth and abnormal function or structure of the central nervous system. The diagnosis may not be evident at birth. However, not all children exposed to alcohol during pregnancy are adversely affected, or affected to the same degree. Expression of FAS appears to depend on other factors including (O’Leary 2004): the timing of alcohol intake in relation to the stage of fetal development; the pattern and quantity of alcohol consumption (dose and frequency); and socio-behavioural risk factors (maternal age/duration of drinking, lower socioeconomic status, race, genetic differences, polydrug use).

A number of alcohol-related birth defects (ARBD) and alcohol-related neurodevelopmental disorders (ARND) have also been described following exposure to alcohol during pregnancy and can be included, with FAS, under the umbrella term of FASD (Hoyme et al 2005; Astley & Clarren 2000). Although children with ARND do not have birth defects, they have significant developmental, behavioural and cognitive problems similar to those of children with FAS.

People with FASD experience lifelong problems, including learning difficulties and disrupted education, increased rates of mental illness, drug and alcohol problems and trouble with the law (Streissguth et al 2004).

The effects of alcohol exposure on fetal development occur throughout pregnancy (including before the pregnancy is confirmed), with the developing fetus being most vulnerable to structural damage during the first three to six weeks of gestation (O’Leary 2004). Effects also vary depending on the dose of alcohol and the pattern of consumption. The most serious of the adverse pregnancy outcomes occur when pregnant women consume high levels of alcohol frequently.

13.2 Discussing alcohol consumption in pregnancy

While there is convincing evidence linking chronic or intermittent high level alcohol intake with harms, including adverse pregnancy outcomes and FASD, there remains uncertainty about the potential for harm to the fetus if a woman drinks low levels of alcohol during pregnancy. It is important that all women of child-bearing age are aware, before they consider pregnancy, of both this uncertainty and the potential risks of harm, so they can make informed decisions about drinking in pregnancy. Health professionals should highlight that:

  • the risk is higher with high alcohol intake, including episodic intoxication (binge drinking)
  • the risk appears to be low with low alcohol intake
  • it is impossible to determine how other maternal and fetal factors will alter risk in the individual.

The high rates of drinking in Australian women, including pregnant women, and the high rates of unplanned pregnancy suggest that, regardless of policy, many fetuses will be inadvertently exposed to alcohol. Assessment of women who have consumed alcohol before knowing that they were pregnant should include appraisal of how much alcohol was consumed and at what stage in the pregnancy. Efforts should be made not to induce unnecessary anxiety for isolated episodes of drinking. Women who drank alcohol before they knew they were pregnant or during pregnancy should be reassured that the risk to the fetus is likely to be low if they had drunk at low risk levels. Women who remain concerned should seek specialist medical advice. Health professionals who are uncertain how to advise pregnant women seeking information concerning the potential for alcohol-related harm should seek expert advice from specialist medical services.

Recommendation

  • Consensus-based
  • IV

Advise women who are pregnant or planning a pregnancy that not drinking is the safest option as maternal alcohol consumption may adversely affect the developing fetus.

Approved by NHMRC in December 2011; expires December 2016

Section 13.4.1 Assessment tools includes example questions that may assist in asking women about their alcohol consumption.

13.3 Practice summary: advising women about alcohol

When

At the first antenatal visit.

Who

  • Midwife
  • GP
  • obstetrician
  • Aboriginal and Torres Strait Islander health worker
  • multicultural health worker.

What

  • Discuss alcohol consumption during pregnancy
    Explain that not drinking is the safest option and the risk of harm to the fetus is highest when there is high, frequent maternal alcohol intake. However, the level of risk to the individual fetus is influenced by maternal and fetal characteristics and is hard to predict.
  • Assist women who consumed alcohol before knowing they were pregnant
    Advise these women that risk of harm to the fetus is likely to be low if a woman has consumed only small amounts of alcohol before she knew she was pregnant or during pregnancy.
  • Take a holistic approach
    If there are concerns about the effects of a woman’s alcohol consumption on the pregnancy, seek specialist medical advice. Women who find it difficult to decrease their alcohol intake will require support and treatment and should be offered referral to Drug and Alcohol services.

13.4 Resources 

13.4.1 Assessment tools 

Please refer to information at beginning of this chapter regarding resources which may be of assistance.

13.4.2 Treatment guidelines

References

  • AIHW (2014) National Drug Strategy Household Survey detailed report 2013. Canberra: Australian Institute of Health and Welfare.
  • Astley SJ & Clarren SK (2000) Diagnosing the full spectrum of fetal alcohol-exposed individuals: introducing the 4-digit diagnostic code. Alcohol 35(4): 400–10.
  • Hoyme HE, May PA, Kalberg WO et al (2005) A practical clinical approach to diagnosis of fetal alcohol spectrum disorders: clarification of the 1996 Institute of Medicine criteria. Pediatrics 115: 39–47.
  • Jones KL, Smith DW, Ulleland CN et al (1973) Pattern of malformation in offspring of chronic alcoholic mothers. Lancet 1: 1267–71.
  • Lemoine P, Harousseau H, Borteyru JP et al (1968) Les enfants des parents alcoholiques: anomolies observees a propos de 127 cas. [The children of alcoholic parents: anomalies observed in 127 cases.] Quest Medical 25: 476–82.
  • O’Leary CM (2004) Fetal alcohol syndrome: diagnosis, epidemiology, and developmental outcomes. J Paediatr Child Health 40: 2–7.
  • Streissguth AP, Bookstein FL, Barr HM et al (2004) Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. J Dev & Behavioral Pediatrics 25: 228–38.
  • 15 The information in this section, including the consensus-based recommendation, is based on Guideline 4 in NHMRC (2009) Australian Guidelines to Reduce Health Risks from Drinking Alcohol (under review). Canberra: National Health and Medical Research Council. Literature on prevalence of alcohol consumption and associated risks during pregnancy published subsequent to the NHMRC guidelines has not been reviewed.
Last updated: 
4 December 2018