Health Care Students’ Attitudes About Alcohol Consumption During Pregnancy: Responses to Narrative Vignettes

Ability to conduct own research: Perceptions of level of education and decision-making skills

A significant point of conversation regarding alcohol consumption during pregnancy stemmed from the belief that women who were “educated” and “professional,” have “a good job,” and are “organized” and “from well-off communities” tend to be “very well informed” and “fairly confident” about the decisions they make regarding their pregnancy, including the decision to drink in low or moderate amounts throughout all three trimesters. Several students alleged that women who were more “educated and stable” were the women who “tend to know more about the effects of alcohol on pregnancy and have more resources to not drink during pregnancy” (Eva, fourth-year midwifery student).

Students who responded to the vignette about Shannon, a woman in her early 30s with an undergraduate degree, a stable job, a group of close female friends, and a decision to only consume a “moderate” amount of alcohol during her second and third trimesters, perceived her to be knowledgeable and informed about the potential risks of alcohol consumption during pregnancy, and noted that it sounded like she had “really done her research.” Students held this belief, even though Shannon’s main source of information on the risks of alcohol consumption during pregnancy were her friends and a blanket statement that she believes there is no conclusive evidence that light drinking during pregnancy will harm her baby. On the contrary, students who responded to the vignette about Kimberly, a woman in her early 20s who lives in a small, rural community, perceived there to be a greater risk during her pregnancy because of the “pressure to drink” and the situation with her partner. Notably, students went on to discuss that their concern for Kimberly was not necessarily because of a binge exposure early in the first trimester, but rather because of the psychosocial factors at play in her life including her young age, marital status, lack of education, region of the province, and potential partner violence.

Students who responded to Kimberly’s vignette spoke more hesitantly compared with those who responded to Shannon’s scenario, and raised additional concerns about patient trust and safety. Students noted that Kimberly was making positive and responsible choices (e.g., refraining from drinking further alcoholic beverages), but perceived that her statement about abstaining from alcohol might not be entirely truthful. This attitude was also prevalent in the students’ responses to the vignette about Jessica, a 30-year-old woman whose family doctor encouraged her to have a couple of drinks to help ease her anxiety regarding her pregnancy. For example, Ruby, a third-year midwifery student, used the phrase “if you can trust that she never drinks alcohol” when discussing Jessica’s situation, and went on to reflect that some women in their care may be recovering alcoholics or binge drinkers, without these women knowing or acknowledging it. Students also raised concerns about whether allowing women to have one or two drinks during their pregnancy would encourage women to drink more and wondered whether certain women, such as Jessica, could “be able to drink one glass of wine and leave it alone thereafter.” Interestingly, students did not hold this attitude in Shannon’s situation and did not perceive Shannon to be at risk.

Rebecca, a fourth-year medical student, noted that there is still “a lot of stigmatization around asking moms about whether they’ve had a couple drinks in pregnancy.” She further elaborated that, despite knowledge that it is not “just alcoholics” who may have children with FASD, it is still sometimes “difficult not to fall for [the] stereotype” that women who drink during pregnancy may be those who come from lower income families and have other social comorbidities, such as trouble with the law, struggles with alcohol use, and lack of formal education. Many students held the belief that low to moderate levels of alcohol consumption were not really of concern for either the mom or the baby (see Coons et al., 2017), and likely have little motivation to dissuade their pregnant patients from drinking occasionally if they do not fall into their view of at-risk pregnancies. As a result of these attitudes, students hold different beliefs about which women should, or should not, be allowed to drink during their pregnancies. Ruby, a third-year midwifery student, discussed one specific example of where recommendations were different for women who were perceived to be educated, compared with those who were perceived to be a higher risk:

My experience in clinical placements has been a glass of wine with dinner once a week in the second or third trimester and beyond is probably okay. And those are recommendations that are selectively made to selective types of people, depending on their educational level, depending on whether or not we have concerns about alcohol and drug use otherwise in the pregnancy, and if that one drink is gonna tip somebody back into binge drinking . . . Often women who have maybe just completed high school or not completed high school and then . . . it usually feels like one end of the spectrum or the other where they’ve gone to university or gone to college . . . So the recommendations that are made to women who don’t have the higher level of education of university or college or beyond, they often aren’t the same recommendations in terms of alcohol use.

When prompted further about why she may hold this particular attitude, Ruby elaborated that this style of recommendation had been passed down to her “not in words but in actions” from her preceptors and identified instances where she picked up on cues of “you said this to this person, but not to this person . . . and noticing that this population gets this spiel and this population gets this spiel and this must be why,” reflecting that these attitudes may be, in part, caused by “classist or racist” beliefs.

Stereotypical beliefs: Perceptions of culture and ethnicity

Students in all three program groups reflected that there is often an “underlying judgment” and observation of shame toward mothers of children with FASD, and tended to focus their discussion on women from “marginalized populations,” including mothers who had “an addiction or an illness,” “First Nations” and “Aboriginal populations [with] a high incidence of FASD,” and “more rural areas . . . that acknowledge they have a higher incidence of . . . alcohol consumption in pregnancy.” Although students acknowledged that FASD “can happen in pregnancies where the mother has just a couple of drinks,” students were more concerned about potentially high-risk populations, including mothers who consume “too much alcohol,” drink “excessively,” or have “chronic alcohol use.” Students noted that these groups may need further intensive support to cut down on their drinking. However, it is important to note the word choices used when describing these populations and the ingrained, often unconscious, attitudes toward communities and populations that are traditionally associated with FASD. The words “too much,” “excessive,” “chronic,” and “alcohol abuse” draw attention to the fact that students still associate FASD predominantly with women who binge drink or consume alcohol on a regular basis throughout their pregnancies.

Students in this study were living and working in a variety of communities across Northeastern and Northwestern Ontario, and took note that their individual placement experiences and patient demographics may have influenced their personal attitudes and beliefs about FASD and alcohol consumption during pregnancy. Several midwifery students spoke of their experiences doing community outreach in Indigenous communities, and described that issues such as alcohol consumption and FASD are often seen in Northern, rural areas. Other students, such as Layla, a third-year medical student, discussed that her educational experiences touched on alcohol consumption and FASD from a “social perspective and how it affects First Nations people.” Layla went on to elaborate that her experiences are directly related to her living in Northern Ontario, because “everybody I’ve ever met who has FASD has been First Nations.” These examples demonstrate that students are making several assumptions beyond their attitudes about the prevalence of FASD in Indigenous communities, including their belief that FASD is a visible disability and that individuals from certain populations or demographic groups may be more or less likely to have a formal diagnosis of FASD. Importantly, although students did hold some stereotypical beliefs, many participants, especially medical students, highlighted the significance of providing culturally sensitive care for these individuals in the North.

Beyond their beliefs about Indigenous and First Nations communities in Northern Ontario, and even while acknowledging that women from many different social backgrounds consume alcohol during pregnancy, participants still tended to speak to already stigmatized populations, perhaps not even aware of their own ingrained perceptions and attitudes. For example, many students ruminated about whether they thought the women in their care were at a “higher risk” of alcohol use or drug use during pregnancy or came from a “population that seem to have a higher risk of FASD,” and implied that screening for alcohol consumption was necessary only in instances where they thought women may be vulnerable. However, these decisions tended to be based on personal feelings and perceptions of the women in their care.

Students struggled to identify whether varying levels of “moderate” amounts of alcohol consumption during pregnancy would be considered problematic and whether they would screen further. For example, Grace, a fourth-year midwifery student, questioned Shannon’s alcohol consumption during pregnancy in Vignette Scenario 1:

I probably might want to see why she’s drinking, ’cause she says she could go the nine months without drinking so does she feel any social pressure, is it because of her job? Does she still want to fit in? Are there other social issues attached to this? That would kind of have to be broken down if she’s willing.

When considering Shannon in the first vignette, some students noted that the amount she describes would give them pause and would be considered an “upper limit” before they started to worry, whereas other students were not concerned about the level of exposure. Interestingly, Grace raised an important point when she stated that Shannon says she could go the 9 months without drinking, but as some students elaborated, even though she says she could go without drinking, she still continues to do so, and some students considered that, perhaps, this would be an instance where they needed to screen further.

Typically, students, such as Sally, a fourth-year midwifery student, also noted the “tone” with which FASD and alcohol consumption during pregnancy were discussed compared with other disabilities such as Down’s syndrome or autism, and identified that because FASD has a known cause, prevention takes a different mood or feeling because it “is considered likely to be a problem for only mothers who are ‘troubled’ and not being ‘careful enough’ in their pregnancy. There’s an element of shame there.” This quote demonstrates the ingrained negative perceptions that are often associated with FASD and mothers who consume alcohol during pregnancy, such as shame, judgment, harm, and the belief that these mothers are bad mothers or bad people. Kylie, a fourth-year midwifery student, was one of only a few participants to elaborate on the issue of alcohol consumption prior to pregnancy and identified the need to understand the woman’s pregnancy in the context of her own life. As she questioned, “How many drinks do they normally consume prior to pregnancy? Has this changed since?” Given the significance of the relationship between alcohol consumption prior to pregnancy and continued consumption during pregnancy, students identified a need to know how much alcohol a woman may be drinking prior to conception and whether she would need help to cut back or stop drinking during her pregnancy.

Harm reduction and binge drinking: Perception of the ability to stop drinking

Students observed that most women, in their clinical experience, abstain from alcohol or significantly cut down their alcohol consumption upon discovering they are pregnant. However, students, such as Eva, a fourth-year midwifery student, acknowledged the reality of providing more rigorous care to certain patients and discussing,

if she is going to be drinking, how to do that in a . . . less harmful way . . . [because] if she felt uncomfortable with the amount she was drinking, unable to stop, I would encourage her to be open with me and we could explore some ways to change the behaviour.

As Eva elaborated, “one or two drinks would be a lot less harmful theoretically than eight or ten drinks in one sitting,” and many students discussed the importance of harm reduction.

Although participants acknowledged that no alcohol consumption during pregnancy was the official recommendation, they also spoke to the reality that conveying this message to all women may not be effective. Several students from all three programs noted that this blanket statement promoting abstinence from alcohol may make some women feel discouraged or as though they are a “lost cause” if they are not able to abstain from drinking during their pregnancy. Instead, many students discussed that harm reduction was a much more positive and beneficial approach in certain situations. As Mackenzie, another fourth-year midwifery student, spoke,

If I had someone who came in and who was having problems with drinking I think I would definitely try to reduce it as opposed to trying to get them to stop completely ’cause that just doesn’t seem very realistic.

Charlotte, a second-year nurse practitioner student, shared a similar belief that it was better not to consume any alcohol at all, but that she would not want the woman in her care to feel judged if she does drink and so she would

try and work with her and see “okay, what can we do? Let’s do what’s best for you and your baby. Let’s work with the resources that we have.” If the person really doesn’t want to stop, I have to do my very best to guide her.

Charlotte’s remark also highlights the importance of building a strong relationship in the patient–health care provider relationship and allowing women to feel supported instead of judged. This sense of trust is incredibly important, as women who do not have faith in their provider may be unlikely to work with them to cut back on their alcohol consumption or may not accurately report how much they are currently drinking. Jacqueline, a fourth-year midwifery student, conversed about the need to “start off whenever we can” by supporting women to achieve practical goals, such as to “cut down from 2 glasses a day to 1. Or to switch to something with a lower alcohol content. Or make sure that they are taking it on a full stomach” to ensure a reduction in the amount of alcohol exposure, even if it does not reach an “ideal situation” of complete abstinence.

However, not all students were as positive regarding harm reduction, and some participants were more jaded when it came to discussing women who may struggle with alcohol. As Sierra, a first-year nurse practitioner student, stated,

It’s a sad thing when it can be prevented. But you can’t stop women that drink from getting pregnant. Even though you have them come in and they’re having their second one [child], you tell . . . Children’s Aid and they just go back to the home anyways, I’m sorry to say. I’m being negative, from experience.

Harm reduction was a controversial topic, and not all students were in agreement that this approach should be employed with patients.

Whereas Sierra spoke in a tired and frustrated manner about her perception regarding the frequency with which women who struggle with addictions may have multiple children with FASD, Braden, a fourth-year medical student, discussed his belief that women need to be thought of “holistically,” and care in the context of FASD needs more of a harm reduction approach. Braden also argued for the need to go beyond just employing the harm reduction approach itself to an actual understanding of why this method may be the best solution for some women:

We need to think about why people are drinking so much during pregnancy or before pregnancy . . . If we don’t address the context in which the alcohol, the drugs, or the smoking are the coping mechanism . . . then we’re going to disenfranchise the moms to be further and separate them from good care and, frankly, make them feel quite crappy about themselves on top of already probably feeling quite crappy about themselves because they know they’re dependent on alcohol.

Braden highlighted the critical importance of not only acknowledging the need to support women in cutting down on their alcohol consumption but also contextualizing the social determinants of health and their contribution to why some women may continue to consume alcohol throughout pregnancy. He went on to emphasize the need to understand the motives behind a woman’s alcohol consumption:

She’s [drinking] for a reason. She’s not doing it just because there’s a cup with a beer in it. There’s a whole series of events that get to the place where there’s a glass of wine in front of the pregnant mom, whether she knows she’s pregnant or not.

As Jacqueline, a fourth-year midwifery student, also said, “You need to address the whole clinical picture and who she is and what brought her to that situation.”

Complex relationship between women and alcohol

In addition to discussing the realities of their clinical experiences, students spoke to the importance of understanding why women drink, both in general and during pregnancy. Several students brought up the perceived culture of normalized drinking during their interviews, and participants conversed about the increasing rates of alcohol consumption and binge drinking among women in Canada. As Eva, a fourth-year midwifery student, stated,

It’s interesting to mesh together that relationship between how people actually consume alcohol versus what the research actually says . . . There’s a normalizing of alcohol consumption . . . So I feel like . . . it doesn’t necessarily reflect the lived realities of people who are drinking during their pregnancies.

In this regard, students often understood that their life circumstances, and perhaps privileged experiences, may often separate them from the women they perceived to be at risk of having a child with FASD. Students also revealed their surprise regarding the current recommended Canadian guidelines, including the Low Risk Drinking Guidelines, given how normalized alcohol consumption has become in Canada. Although many students were familiar with the guidelines, several participants noted that most people, including themselves and their own social circles, drink beyond the recommended quantities and that these behaviors were typical of patterns of alcohol consumption. Eva further hinted that sometimes health care providers may have a “saviour complex,” which entails trying to help patients stop their “bad habits.” However, as students reflected, these approaches are not always “grounded in reality” because students may be unable to reconcile their own life situation with those of their clients who may be struggling with alcohol.

Participants acknowledged that personal and institutional barriers (e.g., lack of access to regular health care) contribute to women’s health, including systemic obstacles, political hindrances, social issues or difficult relationships, financial concerns, mental health disparities, and a lack of social support. Despite acknowledging that a multitude of factors can influence women’s health, students did not provide specific examples of how these circumstances may affect women’s health in general or during pregnancy specifically. However, students did elaborate broadly on how these barriers may affect health in general, as well as how they could interact and compound to influence women’s health during pregnancy. Consequently, participants identified a need to “really access why” a woman may be drinking throughout pregnancy and determine what can be done “to make life healthier, so that the desire to drink is not as strong.” Students were adamant that women who may have an issue with alcohol consumption during pregnancy are often lacking in social support from their families or communities. In particular, students discussed the critical importance of having a supportive social network, which included a positive and sympathetic partner.

Partner involvement and recognition of other risk factors

One important social determinant of health that participants discussed was the issue of partner violence and related social pressure. However, students were only prompted to discuss these issues in a situation that directly mentioned a significant other (i.e., in Kimberly’s vignette), supporting the notion that students focus predominantly on women when counseling about alcohol consumption during pregnancy and preventing FASD. Despite the critical importance of a partner’s involvement during pregnancy and the significant contribution of domestic abuse to alcohol consumption, the topic of partner alcohol use or partner involvement rarely, if at all, came up and only arose in interviews where students were provided with Kimberly’s vignette. In this vignette, Kimberly’s partner and the father of her child continued to drink in front of her, despite Kimberly’s request that he not drink. Kimberly’s partner also encouraged her to drink in certain situations to “help her relax and have fun.”

Every student who was provided with Kimberly’s vignette noted that they were “concerned” or “worried” about her situation. When asked what their first impression was of the scenario, several students first spoke to the partner’s drinking and the need to “flesh that out more” to understand the social context of the relationship. As Eva, a fourth-year midwifery student, questioned, “Does he drink every day? Does it bother her? Does she ever feel unsafe when he’s drinking? . . . It is a red flag for me that he drinks around her and encourages her to drink as well.”

Students in all three programs discussed the notion that working with Kimberly is within their scope of practice, but were uneasy about addressing her partner’s alcohol consumption. Charlotte, a second-year nurse practitioner student, stated that if Kimberly’s partner came to her prenatal visits that she would “reinforce the message that he can have drinks, that’s his choice, but I would suggest that Kimberly doesn’t, because that’s her choice and also because it’s for the safety of the fetus.” The issue of personal choice was an important, and contentious, point of discussion for many students and has been discussed more in depth in Part I of this two part article (see Coons et al., 2017). Sierra, a first-year nurse practitioner student, also emphasized that when providing counseling about alcohol consumption during pregnancy, that she would “tell [patients] if you’re thinking about getting pregnant to abstain and [your] partners as well,” encouraging spouses to be involved and to also limit their own alcohol consumption during the pregnancy.

Perhaps most troubling, several students, such as Reece, a fourth-year midwifery student; Layla, a third-year medical student; and Regina, a fourth-year medical student, noted that the situation presented in Kimberly’s vignette was “pretty normal almost” and “common” in rural and Northern Ontario. As Regina further reflected,

It sounds like it could be a typical Northern Ontario female. I feel like lots of people might be in this situation . . . ’cause I know Northern Ontario has a higher rate of alcohol use. Socially . . . she’s single, unmarried, young, first time being pregnant so . . . that might be difficult for her.

Layla, also a medical student, had similar concerns for Kimberly’s social situation and contemplated that her partner is “continuing to drink in front of her and seems like he’s pushing it on her, so I’d be worried that she’s at risk of drinking during pregnancy.” Layla also elaborated that she would be concerned because Kimberly seemed isolated within her community, demonstrating the need to understand women’s social contexts within their home communities and personal relationships.

In their interviews, students highlighted the potential limitations in access to care in rural and Northern Ontario, both for individuals diagnosed with FASD and pregnant women at risk of having a child with FASD who may require more intensive interventions. Students noted that the risk of FASD may be elevated in rural, Northern Ontario communities, given increased rates of alcohol consumption in these communities, as well as the lack of access to regular primary health care. Students also discussed barriers to care that may contribute to a patient’s isolation, such as travel and transportation, as well as a scarcity of providers who are knowledgeable about substance use in general, substance use during pregnancy, and developmental disabilities or FASD. These attitudes, and students’ remarks presented earlier regarding stereotypical beliefs about FASD, may reflect that they have become desensitized or normalized to these issues based on their experiences in rural and Northern Ontario.