Alcohol Consumption by Women of Child-Bearing Age: A Modifiable Risk Factor

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Mary Johnston,
Division of Child and Adolescence Health,
Public Health Agency of Canada

Table of Contents

• Why be concerned about alcohol consumption?
• What are current alcohol consumption patterns?
• Reasons for alcohol consumption
• Attitudes to alcohol among women of child-bearing age
• Modifying risk factors for alcohol consumption
• References

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Why be concerned about alcohol consumption?

Alcohol as consumed in alcoholic beverages is a teratogen and exposure prenatally may lead to a distinct pattern of birth defects known as Fetal Alcohol Spectrum Disorder (FASD).^{1, 2, 3} The specific outcomes vary with the timing of the exposure, the dose or amount of alcohol consumed, the frequency and pattern of consumption as well as the health, nutritional status and genetic makeup of the pregnant women and other social and environmental factors. ^{4, 5}

The difficulty is that many pregnancies in our society are not planned. Some studies have shown that as many as 50% of pregnancies are unplanned. This can be a problem, as drinking in the early stages of pregnancy, before a woman realizes she is pregnant may have life-long consequences for the resulting child. While over 95% of live births in 2002 were to women between the ages of 18 and 40, women often enter puberty, and therefore their child-bearing years at age 12. In addition, alcohol consumption often leads to risk taking behaviour such as unprotected sexual contact and therefore a risk of unplanned pregnancy.

Understanding the alcohol consumption patterns of women in their child-bearing years is key to understanding the risk level among these populations. It is particularly critical to understand the reasons why women in this age group consume alcohol and what influences their drinking patterns. However, patterns of and attitudes towards alcohol use, as well as reasons for using alcohol, will vary with different age groups, education levels and socio-economic levels among other factors. Therefore, the first step in modifying alcohol consumption is to understand the patterns of and motivation for alcohol use within the different demographic groups.

Figure 1

What are current alcohol consumption patterns?

Adolescent Women

Information regarding alcohol use patterns among young women ages 11 to 18 or 19 are available from a number of data sets nationally, internationally and provincially. The data from the Health Behaviours in School-Aged Children Study (HBSC 2001) (Figure 1) show that in 2001 there was significant underage regular drinking and that this drinking was happening in a high-risk pattern which involved getting drunk ⁶.

Alcohol consumption is a pattern of adolescent risk-taking behaviours that tend to cluster. Using the Health Behaviours in School-Aged Children 2001 data set and cross-tabulating the binge drinking data with those of sexual activity one can see that more sexually active (have had intercourse at least once) young women (35% of young women in grade 9 and 50% in grade 10) had been drunk more than four times as compared with those sexually non-active (have never had intercourse) (10% of young women in grade 9 and 15% in grade 10) (Figure 2).⁷ Poulin and Graham (2001) and Boyce et al., (2003) have both shown that unplanned sexual activity under the influence of alcohol has been associated with inconsistent condom use and having multiple sexual partners.^8,9 Both of these are risk factors for sexually transmitted infections and unplanned pregnancy.

Figure 2

These data are consistent with those from other similar data sets such as the Youth Smoking Survey (YSS), the National Longitudinal Survey of Children and Youth (NLSCY) and provincial and territorial surveys such as the Ontario Student Drug Use Survey ¹⁰ or the McCreary Centre Society Adolescent Health Survey ¹¹.

College and University Women

The next group for which alcohol use patterns can be examined is female college and university students. The 2004 Canadian Campus Survey (Figure 3) shows that alcohol use is very frequent within this population with 33.4% indicating more than weekly drinking. Additionally, for a significant portion of the population the pattern of consumption is a risk-taking pattern of “heavy-frequent” drinking of more than 5 drinks per occasion and drinking weekly. The average age of the undergraduate women was 22 years and 12.8% reported unplanned sexual activity due to alcohol. 42.4% reported at least one indicator of harmful drinking according to the AUDIT screener such as feeling guilty, experiencing memory loss or an injury and having other concerns about their drinking. ¹²

Figure 3

Women

The 2004 Canadian Addiction Survey (Figure 4) reported that 76.8% of women aged 15 and older drank alcohol during the past year and 32.8% drank at least once a week. This rate varied among the age groups as illustrated in the accompanying chart. This study did not ask questions regarding alcohol use during pregnancy.¹³

The 2003 Canadian Community Health Survey, Cycle 2.1 (CCHS) reported on drinking for respondents 12 and over. This survey reported a decline in alcohol consumption in general from 2001 but an increase in both heavy infrequent and heavy frequent consumption. This, of course is a concern when assessing the risk of alcohol use during pregnancy and unplanned pregnancies.

Pregnant Women

Figure 4

The Canadian Community Health Survey (CCHS) asks women who have been pregnant in the last five years about alcohol consumption during pregnancy while the National Longitudinal Survey of Children and Youth (NLSCY) asks women with children aged two and under, comparable questions (Figure 5).^14,15 The CCHS data allows us to examine the frequency and amount consumed, but not the timing during the pregnancy. However, it must be remembered that there are limitations to self-report data and to the longer recall period in the CCHS. As recent studies have suggested that even drinking a small amount of alcohol (the equivalent of 1-2 glasses of wine) regularly during pregnancy has a negative impact on the developing brain, any consumption of alcohol while pregnant can be problematic.^16,17

Reasons for alcohol consumption

In order to provide a starting point for discussing how to effectively modify the risk of alcohol consumption during pregnancy, it is important to understand why women say they drink.

Figure 5

Adolescent Women

Adolescents cite five main reasons for drinking alcohol: to have a good time with friends; to experiment and see what it's like; to feel good or high; to experience its taste; and to relax and relieve tension.¹⁸ This would indicate the following motivational or influential factors on adolescent alcohol use: internal (coping and enhancement) and external (social and conformity) motivations for drinking ¹⁹; strong peer influence; and a need to experiment with new experiences.

College and University Women

For college and university aged young people, the 2004 Canadian Campus Survey found that the patterns of drinking varied with the region, gender, year of study, living arrangements and the context of the drinking occasion. Rates of both heavy infrequent and heavy frequent drinking were significantly higher in the Atlantic provinces, lower in Quebec and higher among those who live on-campus, compared to those living off-campus or with family. There was also a wide variability with where the drinking takes place and the social context. Generally, the larger the group, the higher the average alcohol intake. ²⁰ This would indicate that the motivation for drinking among this population is more external and centred around social and conformity motives ²¹ and that peer influence on alcohol consumption is strong for this population sub-group. Thus the role of alcohol in the social structure of campus life would need to be examined further to create changes in these consumption patterns.

Figure 6

While it is well established that women in general have lower levels of alcohol use and problem use when compared with men ²², women are at greater risk of developing alcohol related health problems and dependence. ²³ This may be partly due to body size, composition and hormonal influences; however social factors related to gender such as social support networks, level of education, employment status, poverty, mental health problems, victimization and violence in relationships all play a role in the development of alcohol related problems. Colleen Dell (2006) in her research update on alcohol use during pregnancy has listed 28 co-occurring conditions experienced by pregnant women who use alcohol, such as violence, abuse, low social support, or low self esteem. ²⁴

Attitudes to alcohol among women of child-bearing age

Figure 7

Health Canada and the Public Health Agency of Canada have commissioned a series of public opinion surveys and focus groups to examine beliefs about alcohol use during pregnancy, awareness and intended behaviours. While general awareness of FASD and the harms of alcohol consumption during pregnancy was high, understanding of the life-long nature of the disability caused by prenatal alcohol consumption was low. The awareness and understanding of harms caused by alcohol consumption during pregnancy and fetal alcohol spectrum disorder vary with the region of the country, age, education level and socio-economic level of the women. ²⁵

The public opinion surveys conducted in 2002 by Environics (Figure 6) among women and their partners age 18 to 40 indicated that 64% of women said that cutting down or stopping the use of alcohol was “one of the most important things to do during pregnancy”. However, while 94% believed that “alcohol use during pregnancy can lead to life-long disabilities in a child” only 70% believed the “any alcohol consumption during pregnancy can harm the baby”. There was also confusion regarding the use of a “small amount” of alcohol with 46% of women answering that this can be considered safe and 23% stating that a moderate amount can usually be considered safe. Figure 6 shows the data from the three public opinion surveys conducted in 1999, 2002 and 2006 which all show similar patterns of beliefs.

Focus group work conducted for the Public Health Agency of Canada in 2005 among women age 18 to 40 with incomes of $60,000 or less indicated that while there was general awareness that drinking large amounts of alcohol regularly was harmful, there remained a belief that occasional drinking would be safe. In addition, there is a wide variation of what women of all ages understand to be low-risk, moderate, heavy and binge drinking. Women in this study described binge drinking as: no longer being in control; becoming sick; passing out; drinking 8 to 10 drinks in one evening or drinking heavily for an extended period of time such as a weekend.26 Women in the 2006 Environics study (Figure 7) described light drinking as one to two drinks in an evening (91%), moderate consisted of up to four drinks, while heavy drinking was three to six drinks.²⁷

Modifying risk factors for alcohol consumption

Figure 8

From the evidence presented above, one can see that addressing alcohol use during pregnancy would require a range of strategies, depending on the age, education level, socio-economic level, and context of the women's lives. These strategies would range from health promotion activities targeted at addressing societal attitudes about alcohol, to primary, secondary and tertiary prevention activities for those misusing or dependant on alcohol. One can see from the data in Figure 8 that
addressing societal attitudes about alcohol use needs to start early, with health promotion activities prior to initiation of regular alcohol use. A concerted effort is required to influence patterns of alcohol use during adolescence, through college and university and in understanding of the long term consequences of alcohol consumption during pregnancy.

Once alcohol use has become a regular pattern, consistent messages regarding low, moderate and high risk drinking are necessary. The variation on what is considered “heavy” and “binge” drinking needs to be clarified for the Canadian population. Women involved in the 2005 focus group work, mentioned above, felt that the messages had to grab attention and provide sufficient information regarding the severity of the outcome if they were to be effective. They felt that some shock value was necessary and that women had to have enough information to reach their own conclusions. Awareness of the long term impacts of alcohol use during pregnancy is important but the messages need to be tailored to ensure that the recipients also have the information they need and feel empowered to take action to make changes in their lives. Partnerships need to be established and maintained with health care providers, the alcohol production and distribution industry and the hospitality industry to ensure consistent messaging regarding socially responsible drinking.

For women most at-risk, there is a need to address some of the factors influencing their need to use alcohol to cope with adverse circumstances in their lives. Effective woman and family centred referral, treatment and follow-up services need to be available and accessible. For many women at-risk of using alcohol during pregnancy, developing social support networks that can help address some of the underlying risk factors is necessary to assist in planning for and maintaining alcohol free pregnancies and healthy birth outcomes.

In essence, the population of women of child-bearing age would need to be segmented and the motives and factors influencing alcohol-use in each of the sectors carefully analysed and understood in order to design effective approaches to health promotion and behaviour change. Effective social and environmental supports would need to be accessible for each population segment to assist them in their personal health behaviour change maintenance. Much of this work has been done, but much more still needs to be understood and coordinated into an integrated approach for Canadian women.

References

1. Jones, K.L., Smith, D. W. et al (1973). Pattern of malformation in offspring of chronic alcoholic mothers. Lancet 1(815): 1267-71.
2. Randall, C. L. and Taylor, W. J. (1979). Prenatal ethanol exposure in mice: teratogenic effects. Teratology 19(3): 305-11.
3. Randall, C. L. and Riley, E. P. (1981). Prenatal alcohol exposure: Current issues and the status of animal research. Neurobehavioral Toxicol Teratol 3(2): 111-115.
4. Sood, B., Delaney-Black, V. et al (2001). Prenatal alcohol exposure and childhood behavior at age 6 to 7 years: I. dose-response effect. Pediatrics 108(2): E34.
5. Bingol, N., Schuster, C., Fuchs, M., Losub, S., Turner, G., Stone, R. K., et al (1987). The influence of socioeconomic factors on the occurrence of fetal alcohol syndrome. Adv Alcohol Subst Abuse;6(4):105-18.)
6. Boyce, W., Young People in Canada: their health and well-being. 2004, Health Canada
7. Ibid
8. Boyce, W., Doherty, M., MacKinnon, D. & Fortin, C. (2003). Canadian Youth, Sexual Health, HIV/AIDS Study: Factors influencing knowledge, attitudes and behaviours. Toronto, Council of Ministers of Education, Canada. www.cmec.ca
9. Poulin, C., & Graham, L. (2001). The association between substance use, unplanned sexual behaviours among adolescent students. Addiction 96 (4): 607-621.
10. Adlaf, E. M., Paglia-Boak, A. Drug Use Among Ontario Students 1977 -2005. CAMH Research Document Series No. 16 (2005). Centre for Addictions and Mental Health, Toronto, Ontario
11. Tonkin, R. S., Murphy, A., Lee, Z., Saewye, E. & The McCreary Centre Society (2005). British Columbia youth health trends: A retrospective, 1992 - 2003. Vancouver, B.C. The McCreary Centre Society.
12. Adlaf, E. M., Demers, A. & Gilksman, L. (Eds.). Canadian campus survey 2004. Toronto, Centre for Addictions and Mental Health. 2005. http://www.camh.net/research/areas_of_research/Population_life_course_studies/population_life_course.html
13. Canadian Centre on Substance Abuse (2004), Canadian Addictions Survey. Ottawa. www.ccsa.ca
14. Dell, C. & G. Roberts. Research Update - Alcohol Use and Pregnancy: An Important Canadian Public Health and Social Issue. Public Health Agency of Canada. 2006.
15. Canadian Perinatal Health Report 2003 , Health Canada, 2003.
16. Savage, D. D., Becher, M., de la Torre, A. J. & Sutherland, R. J. (2002). Dose-dependent effects of prenatal ethanol exposure on synaptic plasticity and learning in mature offspring . Alcoholism: Clinical and Experimental Research, 26(11): 1752-1758.
17. Sood, B., Delaney-Black, V. et al (2001). Prenatal alcohol exposure and childhood behaviour at age 6 to 7 years: I. dose-response effect. Pediatrics 108(2): 1-9.
18. Johntson, L. P., O'Malley, P. M. & Bachman, J. G. (1998). Alcohol use among adolescents. Alcohol Health and Research World 22(2): 85-93.
19. Cooper, M.L. (1994). Motivations for alcohol use among adolescents: Development and validation of a four-factor model. Psychological Assessment, 6, 117-128.
20. Read, J. P., Kahler, C. W., Wood, M. D., Maddock, J. E. & Palfai, T. P.. Examining the Role of Drinking Motives in College Student Alcohol Use and Problems. Psychology of Addictive Behaviours 2003. 10(1):13-23.
21. Canadian Centre on Substance Abuse (2004). Canadian Addiction Survey: Prevalence of Use and Related Harms: Highlights. Ottawa.
22. Cormier, R. A., Dell, C. A. & Poole, N. (2003). Women's health surveillance report. A multidimensional look at the health of Canadian women. Ottawa: Canadian Institute for Health Information.
23. Dell, C. A., & Roberts, G. (2006). Research Update - Alcohol Use and Pregnancy: An Important Canada Public Health and Social Issue. Public Health Agency of Canada. Ottawa
24. Environics Research Group, Awareness of Alcohol Use During Pregnancy and Fetal Alcohol Syndrome: Results of a National Survey. (2002). Health Canada, Ottawa.
25. Corporate Research Associates Inc., (2005). Qualitative Research Around Knowledge of FASD. Public Health Agency of Canada, Ottawa.
26. Environics Research Group, Alcohol Use During Pregnancy and Awareness of Fetal Alcohol Syndrome and Fetal Alcohol Spectrum Disorder: Results of a National Survey . (2006). Public Health Agency of Canada, Ottawa.

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