 And I'm going to turn this over to Sarah Ward. Sarah Ward is a project officer at the Foundation of Alcohol Research and Education, the Foundation of Alcohol Research and Education, or F-A-R-E, in Australia. And she's going to be speaking to us about women want to know, engaging health professionals and talking to pregnant women about alcohol. So with no further ado, Sarah Ward. Thank you. Thanks, Lorraine. And it's great to see so many people from all across the world. I myself am in sunny but cold Canberra here in Australia. So as Lorraine mentioned, my name's Sarah Ward and I'm from the Foundation for Alcohol Research and Education, and we're Australia's leading charity working to reduce alcohol-related harm. I'd like to begin by acknowledging the traditional owners of the land in which I am situated, which is the Ngunnawal people, and pay my respects to their elders past and present. I'd also like to acknowledge the First Nations people from around the world. So the project that I'm presenting on today is an Australian project, and all of the data that I'm presenting is Australian, and the alcohol guidelines are from Australia. But I would encourage people across the world to have a look at your own national guidelines if you're not sure of what they are. So I'm going to begin by talking about the drinking patterns of Australian women. So most women in Australia consume alcohol, in fact, 77% of women consume alcohol, and women continue to drink during pregnancy. We know that 47% drank when they were pregnant, but before they knew that they were pregnant, and that one in five continued to drink even after knowledge of their pregnancy. And this is much higher than rates for Canada where 11% of women drink during pregnancy. So often people think that women aren't drinking during pregnancy, that all women know that it's not a good idea to drink during pregnancy, but it does happen and is continuing to happen in Australia. So alcohol consumption in pregnancy differs with age, and this is probably not the result that you're expecting. This is data from our National Household Survey, and it shows that women who are older who are aged over 36 and who are generally from higher income and higher educational statuses are more likely to continue drinking after knowledge of their pregnancy. And this is compared to women who are under 25, in which 90% of them stop drinking as soon as they become aware that they're pregnant. So unfortunately what we don't know from this data is how much alcohol has been consumed or when in the pregnancy it is being consumed. And there are many theories as to why older women are continuing to drink during pregnancy and whether they are drinking a glass of wine each night with dinner and therefore less likely to give that practice up as opposed to younger women who might be binge drinking before they find out they're pregnant, but when they find out they're pregnant they completely stop. So why is alcohol consumption during pregnancy such a problem? So alcohol is so damaging because it's a tarratogen and a tarratogen is a substance that's known to cause birth defects. Other tarratogens include rubella, zalidomide and exposure to X-ray radiation. Alcohol passes freely across the placenta and because the alcohol is so small in size and is developing it has very minimal ability to metabolise the alcohol unlike an adult and the blood alcohol concentrations within the fetus can reach levels that are the same if not higher than the woman's. And this exposure to alcohol results in fetal damage and can result in miscarriage and still birth as well as birth defects and fetal alcohol spectrum disorders which I will talk about in a minute. The other thing to realise is that all alcohol is harmful, it doesn't matter if it's wine or if it's beer or if it's spirits they all cause harm. And because the fetus is developing throughout the pregnancy there's actually no safe time in which alcohol can be consumed. So yeah there's really no safe time. As well as there being no safe time during pregnancy there is no safe limit of alcohol that has been found either. We know that the level of harm to the fetus is related to the amount of alcohol that is consumed and this means that at higher levels of alcohol consumption and higher frequency of drinking more harm is likely to occur but smaller amounts of alcohol can also cause harm. The thing to be aware of is that we just haven't found a cut off point in which no harm occurs and effects have been found at four drinks on one day on an occasional basis have been found to increase the risk of child mental health problems. Two to three drinks per week has been found to increase the risk of spontaneous abortions up to 16 weeks and two to two and a half drinks once or twice a week has been found to increase the risk of neurodevelopmental problems and premature birth and these are really quite low levels of exposure in which alcohol is being found so we're talking less than a bottle of wine a week. So for these reasons in 2009 Australia's National Health and Medical Research Council took what's called a precautionary principle and decided that to recommend that no alcohol consumption during pregnancy is the safest option and when we speak to pregnant women this is really the clearest message that we can give. The other thing to keep in mind is that each woman and each pregnancy is different so if a woman potentially drank in a previous pregnancy and her child was fine that doesn't mean that if she drinks in this pregnancy that her child will be okay. It's really difficult to tell who will be affected or not affected and there's a broad range of effects that are possible. So exposure to alcohol also comes under an umbrella term which is fetal alcohol spectrum disorders or FASD or FASD as we call it in Australia and there are three, within Australia there are three main diagnoses and these are fetal alcohol syndrome, partial fetal alcohol syndrome and neurodevelopment disorder alcohol exposed. So fetal alcohol syndrome is the one that people are most aware of and it's associated with central nervous system deficits particularly in the structure of the brain and the functioning of the brain that's also commonly associated with facial anomalies and growth restrictions. People who have partial FAS and neurodevelopmental disorder alcohol exposed can have some or all of the symptoms of FAS but not potentially to the same degree as a person with FAS. So the organ that is most susceptible to alcohol damage during pregnancy is the brain and the effects of alcohol exposure on the brain manifest themselves in a variety of ways. This includes poor memory and poor impulse control. It's really about cognitive impairments and about executing functioning deficits. People with FASD are not dissimilar to people with autism in that the way that they think in the way that they look and understand the world is different to how other people think and understand the world. So FASD is a lifelong condition. People don't grow out of brain damage and they may only ever reach a certain level of cognitive understanding. However, most people with FASD don't look different. It's often a myth that people think that they look quite different. Another myth is that people think they have a low IQ but most people with FASD don't have a low IQ. It's really about how they understand the world and how they interpret information. So these are some really compelling reasons why women shouldn't drink during pregnancy but not all women and not all health professionals know this information. And I think probably across the world we haven't been great at communicating this information to our health professionals. So what is the role of midwives and health professionals in this situation? So when women are pregnant, as you're aware, they encounter a huge range of information from a variety of sources but discussions with midwives offers privacy and confidentiality. It's a non-judgmental environment. It's an ongoing trust-based relationship as well as allows for accurate and personalized information at the right time. And each time that a midwife meets with a pregnant woman, there's an opportunity to discuss alcohol and eventually prevent FASD from occurring. However, in Australia and other places, awareness about alcohol guidelines and how to speak to pregnant women has been low amongst health professionals and this has really been the background to why the women want to know project came about. So in 2012, our Federal Government Department of Health asked the Foundation for Alcohol Research and Education to undertake a project to raise awareness about the alcohol guidelines with health professionals and also to work out what sort of ways we could increase health professionals initiating these conversations with women who are pregnant or planning pregnancy. For people who don't know, Australia's National Health and Medical Research Council released their most updated guidelines in 2009 and guideline 4 is around pregnancy and breastfeeding and for maternal alcohol consumption can harm the developing fetus or the breastfeeding baby and for women who are pregnant or planning pregnancy not drinking is the safest option. So the Commonwealth Government recognised that awareness about these guidelines was low amongst health professionals and asked us to undertake this project to improve it. So in undertaking this project, it's been quite a long time coming. It's been over 12 months. We've worked with a number of health bodies including the Royal College of Obstetricians and Gynecologists, the Australian College of Midwives and the Maternity Coalition and we took a methodological approach in that we undertook a literature review and audit of existing resources. We consulted extensively with health professionals and communication experts and we undertook a pre-intervention survey to understand current practices by health professionals and we're developing some project outputs which includes online training for midwives which I'll speak about later on. So audit and literature review showed that health professionals and I'm sure you're all aware of these encounter a range of barriers when discussing alcohol consumption with pregnant women. In particular, they can be concerned about the woman's comfort in having these conversations. They're concerned about their own lack of knowledge about alcohol pregnancy and unsure what to say and often there is an assumption made that alcohol is not relevant to the woman that the woman either knows that alcohol consumption during pregnancy is not a good idea or that she is not drinking and so these questions are not asked and these barriers result in midwives lacking in confidence and often avoiding the subject. We know in our pre-intervention survey that many midwives said that they did speak to women about alcohol pregnancy but when we asked what advice they gave and what their knowledge about the effects of alcohol and pregnancy their answers were a little bit more vague. We also found that there are no national resources in Australia that are around to support health professionals in discussing alcohol and pregnancy and this is something that the women want to know project has aimed to rectify. So I guess an important thing for midwives to know is that conversations with women about alcohol are wanted, they're welcome and they're worth it. It shows that women are often willing to make changes in their lives and they want to provide the best for their babies. Women think that health professionals should ask about alcohol and pregnancy. Overwhelmingly 97% think that they should ask. They consider that health professionals particularly their midwives to be the best source of information on alcohol use during pregnancy and they trust the advice that they're given and they're likely to change their behaviors if they're advised to do so. So how do you go about having a conversation with women and what information about should that conversation contain and one important thing that I want to stress is in order to talk about alcohol with pregnant women you don't need to be an expert and you don't need to be an addiction specialist to have these conversations. It's just raising the topic that is the most important thing. So there are many ways in which you can have discussions with women. They don't need to be prescriptive and of course midwives talk to women about a range of issues all the time but for alcohol one way that might help you to frame a discussion is to use the 5a's approach and these are ask, assess, advise, assist and arrange. So how do you ask about alcohol? So questions about alcohol can be built into broader discussions about general health and this really lets the woman know that it's part of a standard process and that she's not being singled out. It's best to begin with open-ended questions like I ask everyone that I see about their health as well as their alcohol use. Is it okay if we talk about that and then when you see the woman again you can begin by I remember last time we talked about alcohol. How are you going with that? Has anything changed? Open-ended questions really allow the conversation to flow and for ideas and to be explored between you. So it's important to avoid asking questions like you're not drinking are you or I assume you don't drink right? So these are really negative questions and the only answers that a woman can give is no and in asking these kind of closed questions it's difficult for the woman to give an honest answer if she is drinking and if she is having any difficulties it's really difficult for her to open up and talk about them. So when asking about alcohol we always need to aim to be non-judgmental. We need to listen attentively to her concerns. Refrain from making any negative comments or reactions and focus on the health of the mother as well as the health of the baby. So how do you assess alcohol use? There's many ways to assess alcohol use. We would recommend that it's best to use a tool and a tool that has been validated because this means that you're asking questions in a non-judgmental way and in a way that will give you a really accurate picture about what a woman is drinking. So we recommend using the Audit C which is the Alcohol Use Disorders Identification Test. It was first developed by the World Health Organization in 1989 and it's easily found on the internet if you just google Audit C. It has three short questions which are how often do you drink? How many standard drinks do you have on a typical day when you are drinking? And how often have you had five or more standard drinks in one day? So each question gets a score and you get a total out of 12. So then the advice that you give the woman is dependent on the score that she gets in her Audit C which is why we recommend using a validated tool. So for women who have stopped drinking completely it's best to provide positive reinforcements such as that's really great that you're not drinking. This is really the healthiest thing for you and your baby and alcohol can harm the development of the baby during pregnancy so it's important that you remain alcohol-free for the rest of your pregnancy. Is this something you think you can do? It's also really important to reassure women. Many women will have had a drink early in pregnancy or they might have had a big night out before they knew they were pregnant and often they're very worried about this. It's really difficult for us as health professionals in this situation and it's not possible for us to say with any certainty that no harm has been caused but if the amount that she drank was low or if the occasions in which she drank were few then the risk of harm is likely to be low. But what is really important is that we focus on the future. It's never too late to stop drinking during pregnancy so even if she had had a slip-up and had that big night she can still stop drinking from here on and that doesn't matter when you see the woman in pregnancy if she's in her first, second or third trimester. And any alcohol consumption in pregnancy should be considered harmful but higher levels of consumption and more frequent consumption are caused for concern and with those women they need to be advised that the risk of health harms not only to themselves but to the baby increase with the increasing amounts of alcohol. We'll talk more about this now. So moving on to assist. So some women will find it difficult to be alcohol-free during pregnancy and this is one of the objectives of speaking to all women about their alcohol consumption during pregnancy. It's to identify early those women who might be drinking at levels that are causing either themselves or their fetus harm or who are having trouble being alcohol-free. For these women a short conversation of five to ten minutes or what's called a brief intervention can be undertaken and the thing with brief interventions is that they're really brief they don't need to be a long time and a brief intervention aims to raise awareness about the woman's alcohol use and increase that person's confidence and motivation to change. They explore both the positives and negatives of why a woman is drinking. For example a positive for a woman might be that she says that a glass of wine with dinner helps her feel relaxed but when you ask about the negatives she does say that it makes her feel tired and quite irritable the next day. And at this point you want to create some dissonance and focus on those negatives. So asking her about what the benefits for her might be of being alcohol-free or how she would like things to actually be and in that case she might say something like well I guess if I wasn't drinking then I wouldn't feel so tired the next day. So it's really about creating those ideas in which she can start to see some examples of change. So from here you want to encourage the woman to think about strategies that will help her to be alcohol-free such as do you think your partner or your friends would consider being alcohol-free to support you in this time or on those social occasions where people ask you if you'd like a drink and you're not ready to tell them about the pregnancy do you have some ideas about what you might say to those people? It's important that brief interventions are most effective that when the strategies that are being put forward are those being put forward by the individual themselves as this allows them to feel control. So you need to allow her to say well I could get a lemonade instead of a vodka it essentially looks the same or maybe I can say to people that I'm on a health kick or I've got a big meeting the next day and I don't want to drink this evening and you can say that sounds like a really great idea I'm really pleased that you've come up with these suggestions. You also want to find out how confident she is at making these changes such as do you think you'll be able to follow these strategies through? Is there anything else that would make you feel more confident or is there any further support that you would need? And then you want to check back in at the next appointment when you see her and see how she's going and say remember last time that we talked about alcohol use how are you going with that and have a discussion from there. So for some women they will continue drinking anyway and it's not a magic bullet and not everyone that you speak to will stop drinking and there are many reasons why women continue to drink during pregnancy even after they're aware of the dangers. This is particularly true if she has or is experiencing violence. In a study of 80 mothers in America who'd given birth to a child with FASD 95% had been seriously sexually, physically or emotionally abused as a child or an adult and 72% felt unable to reduce the alcohol use because they are in an abusive relationship. So high or frequent alcohol consumption is rarely a single issue within a woman's life. Therefore we really need to be empathetic and move on from just thinking I need to show her how bad drinking during pregnancy is to thinking even though she knows the facts about drinking during pregnancy she continues to drink. I wonder why that is. Maybe it's an attempt to cope with her problems. I wonder how I can support her in this. This photograph is of a woman called Nancy Poole who is a Canadian researcher who has worked in the field for a long time and she's from the British Columbia Center for Excellence for Women's Health which is a bit of a mouthful but again you can Google her, Nancy Poole which is fantastic. She talks about trauma-informed practice and this is really sort of changing the way that we think about why women aren't stopping their drinking. So it's important again for me to stress that talking about alcohol consumption during pregnancy doesn't mean that you need to become an addiction specialist or that you need to solve all the problems of the world but these conversations are really about facilitating for the woman to be able to seek support that she might need and to help prevent FASB from occurring. There are also issues around child protection that need to be considered when a woman is drinking at high levels of alcohol consumption and if she has other children but it's very difficult for me to go into these because each jurisdiction has their own policies and procedures to do this but again I'm sure you all are aware of them and I would recommend finding out about more of them if you're not. So as we've mentioned some women need additional support and for some women it's appropriate that we refer them on to other services. As I said you don't need to take on all of the problems in the world and you don't need to try and solve everything so but it is important to refer if and when necessary so this should be particularly for women who are scoring above eight on audit C those women who have expressed an interest in seeking help or for women that have more complex needs. So it's important to know that often if women are having a difficult time about with their drinking or stopping their drinking this might not come out in the first conversation that you have with them about alcohol so it's important to ask and re-ask and check back in with them. It's quite difficult for me to talk about referral processes because each local drug and alcohol service has their own processes. However what you generally will need for drug and alcohol services are the woman's contact details and her name. You'll need to find out from the woman the best time for her to be reached to make an appointment with the service. Usually her consent is required to give out the details so that she agrees to the service contacting her and it's often good for a service if you know a little about her goals whether it's to be alcohol free or something else and they should really be her goals not your goals as a health professional. You need to make clear in the referral that the woman is pregnant as this might make accessing services faster and it's important to complete referral information as soon as possible preferably while the woman is still with you so something along the lines of it's really great that you want to seek some additional support and help. I can give the local drug and alcohol service a call now if that's all right with you and we can see when they can fit you in. If you're in Australia information is available in each state and territory 24 hours a day for health professionals as well as for women for anybody that is concerned and information about them can be found at alcohol.gov.au there is unfortunately a separate number for each state and territory but there is one in each state and territory which is fantastic. So lastly I wanted to show you some of the resources that we've developed for the women want to know project. We've been developing resources for health professionals which are a sort of quick summary about how to have these conversations and we've developed a leaflet for women themselves that can be given by the health professional at the end of a conversation. So once you've had a conversation with a woman you can give her a leaflet and she can take it away and read more information. This will be available soon on alcohol.gov.au I should type that in the comment box shouldn't I? There we go. We've also been working with the Australian College of Midwives and I have to say a great thanks to them they've been fantastic to develop an online training program and this will be free to all midwives whether you're a member of the college or not for two years and it will be available shortly but this little presentation has sort of been a mini taste of it. So in conclusion I wanted to say that it's safest for women not to drink during pregnancy and really this is the clearest message that we can give them as health professionals. Midwives have a really important role in providing this information to women when they are pregnant or planning pregnancy. When you're speaking to women about alcohol you can use the 5a's approach to frame the discussion if that helps you and this is ask, assess, advise, assist and arrange. You can really feel reassured that women want to know this information and they expect their health professionals to bring up conversations about alcohol with them. They're likely to make changes if they're advised to do so however this isn't a hundred percent and don't be disheartened if she doesn't stop drinking but try and understand more about what might be happening in her life that is impacting on her alcohol use. And in Australia the women want to know project will be launching soon hopefully in the next couple months and will provide resources and online training to midwives to assist them in having conversations with women about alcohol and pregnancy. And again internationally I would recommend having a look at what your national alcohol guidelines are and what resources exist in your area. So that's the end of my presentation. You're free to email me if you'd like to receive information about when the project is launching more than happy to email out all the resources that we've been working on and I think that's it from me. Thank you so much Sarah. I think so much for your presentation and I think many of us will feel a lot more confident now about asking about alcohol during the anti-native period. I know a lot of us get asked these questions so that's really really useful. There has been a couple of questions that have come up in the chat box. I think Deb asked will the slides be available? Yes you're more than welcome to have my slides. Thank you so much. And I think Jean asked do you have a handy guide to what constitutes the standard drink? Oh yes that's a good question. Standard drinks unfortunately differ by country which is why I didn't include them in the presentation. If you're in Australia either alcohol.gov.au or the National Health and Medical Research Council of Australia have links to what a standard drink is. They have a little chart that you can print out and that will be also in our resources when we put information up on the web as well. But if you're in other countries they're called other names so in the UK they're called Units and in America they're still standard drinks but they're a slightly different size so I would look up what your health departments probably the national health departments are recommending. Okay and Jean carries on to say what about a pictorial guide for women? For standard drinks? Yeah the ones on alcohol.gov.au and the National Health and Medical Research Council are little pictures and they have standard drink information underneath them so there's a picture of a wine glass with 100 mils and that says one standard drink so yes there's little pictures so you can if you're going to use Audit C for example you can have that little chart in front of you and ask the woman to identify which drinks she's actually drinking. Okay thank you because I think a lot of the time they always talk about quantified, quantified, quantified because one person's lots of alcohol is not the same for someone else we've all got different ideas on what constitutes amounts and Audrey asks is there some good research you can point to about mums drinking and breastfeeding that will show the effects of alcohol on babe? The alcohol and breastfeeding there isn't as much research again I would point to our National Health and Medical Research Council alcohol guidelines there's a chapter about alcohol there's some information about breastfeeding breastfeeding is slightly different in that it can still cause harm to the baby but it won't result in fetal alcohol spectrum disorders because the baby is already born but it certainly is not good in terms of lactation and sleeping as well as the mother's ability to care for the baby Australian Breastfeeding Association has a little app which I should know the name of and I've forgotten but I can find out that women can download onto their phone and it will show you the time where you can put in the time when you last had a standard drink and depending on your weight can work out when the alcohol should have left your body what is recommended is that for women who are breastfeeding that no alcohol consumption is the safest thing but that if they are going to drink they should not drink within the first month of birth and until a breastfeeding pattern is established and if they are really keen on drinking that they consider how they're going to do that so they can either breastfeed before they drink or they can breastfeed and then put that breastfeeding in the fridge and so there's sort of different strategies but yeah I can certainly the National Health and Medical Research Council guidelines have probably got the best evidence in them around our con breastfeeding Thank you Sarah and I can look up that app and I'll pop it up on the Facebook for everybody and Holly Sparrow asks unfortunately docks cannot protect babies against this kind of abuse until they are born do you think this is ever likely to change? I do think it's likely to change because in Canada there are different services so if we can identify women early in pregnancy there's a service in Canada which I think is called She-Way which thanks Kate for FeedSafe for the app the She-Way in Canada tries to identify women who are struggling during their pregnancy and put in place support before the baby is born so I think it's really about changing our mindset so rather than waiting until the baby is born to put in support that we put in support before the baby is born because there's lots of lots of things that are probably going on and if we can put in support in terms of alcohol and drug services mental health services domestic violence services whatever that woman needs then potentially we can help prevent a baby being born with FASD and often women who have a child with FASD will go on to have further children with FASD often because those issues in their lives are not resolved whether they're to do with violence or other things in their lives so if we think about identifying those women really early we can help support those women rather than wait until afterwards after once the baby is born Thank you and Melissa asks what do you think poses more risk a breastfeeding woman having a glass of wine once or twice a week or a woman weaning her baby early and feeding Bob an artificial breast milk substitute so that she can have the occasional glass of wine because that happens often as a result of the information given to women that is unsafe to drink while breastfeeding and I think this is a great pity and potentially much more unsafe for Bob Indeed. I think the best evidence we have is that breastfeeding is the best thing that a woman can do and breastfeeding for a longer amount of time is the best thing that a woman can do for the health of her baby once it's born and I guess I would again appeal to the woman's sense of wanting to do the best for her child so if during pregnancy she has done the best for her child by being alcohol free as well as avoiding soft cheeses and all the other millions of things that women are meant to do then once the baby is born she also wants to continue to be give her baby the best start possible and that would be breastfeeding rather than drinking alcohol I would say that breastfeeding would be a much higher weight in terms of health for the baby rather than her drinking an occasional glass of wine and she's got her entire life to drink that occasional glass of wine there's sort of such a small chance when her baby is small that if she's not drunk for nine months if she can just push it a bit more then it would be certainly helpful to the child that's my personal opinion Thank you Sarah and I know that we all have some limited time in consultations do you think there's other things we need to be aware of beginning to begin talking about alcohol? Yeah certainly there are absolutely limited time in consultations and other things to be aware of is the room comfortable is someone else present in the room and that can have implications if it is her partner for example and if she's experiencing violence are there children in the room that need looking after do you need an interpreter all those sorts of things so it can be difficult in those situations to discuss alcohol consumption and it might not be the appropriate time I guess what I wanted to get across is that you can have these conversations multiple times throughout the pregnancy often what we hear is that a woman is asked about alcohol pregnancy when she goes through say a booking in process when she first comes to see a midwife and then is never asked ever again and a lot can change within the process of a pregnancy so it's good to check in and it might not be appropriate that first time but there should be other times and maybe you can do this on the phone or other situations in which you're having conversations with the woman thank you I think that really makes sense okay I think you have time for one more question or a couple more questions would anybody like a microphone any more questions well thank you so much Sarah it's been absolutely brilliant this is a really topical for midwives thanks you're brilliant wonderful presentations this Lorraine thank you very much we will start clearing down the room and preparing oh maybe one more question and preparing for the next speaker thank you Sarah thank you