Intergovernmental committee on Drugs working party on Fetal Alcohol Spectrum Disorders
Fetal Alcohol Spectrum Disorders in Australia: An Update
11.2 History of the Australian policy
Alcohol and pregnancy policy in Australia has undergone a number of changes over the past 20 years. In the 1990s the National Health and Medical Research Council (NHMRC) recommended that women abstain from alcohol during pregnancy (NHRMC 1992). Following a review of the literature, the policy was changed in 2001 to advise that a woman who is pregnant or might soon become pregnant ‘may consider not drinking at all’. The policy went on to state that if a woman consumes alcohol during pregnancy she ‘most importantly, should never become intoxicated’ and ‘if a pregnant women chooses to drink, over a week, she should have less than 7 standard drinks, and, on any one day, no more than 2 standard drinks (spread over at least two hours)’. The guidelines also advised ‘that the risk is highest in the earlier stages of pregnancy, including the time from conception to the first missed period’(NHMRC 2001).
The 2001 NHMRC guidelines were not universally supported across Australian jurisdictions and health professional organisations. They were adopted without alteration by only three organisations in Australia: the Australian Government Department of Health and Ageing, the
Western Australian Drug and Alcohol Office and the Tasmanian Department of Health and Human Services. The perception that there is insufficient evidence to conclude that any level of alcohol consumption during pregnancy is low-risk is prevalent in policy from across Australian State and Territory governments. The National clinical guidelines (NCG) for the management of drug use during pregnancy, birth, and the early development years of the newborn (2006), commissioned by the Ministerial Council on Drug Strategy, provide the NHMRC 2001 recommendations with a caveat that they are not, in the opinion of the authors, supported by sufficient evidence to conclude what, if any, level of alcohol consumption during pregnancy is completely safe (Ministerial Council on Drug Strategy 2006). The Victorian Department of Health provides the NHMRC recommendations while advising that a safe level of alcohol consumption during pregnancy has not been determined. However, none of the Australian policies and guidelines reviewed in 2006 mentioned the basis for their recommendation of abstinence. All the Australian medical and nursing organisations that provide guidelines on alcohol and pregnancy promoted abstinence as either the only option or the preferable or safest option. None of the policies, with the exception of that of the Australian College of Midwives, which endorses the National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn, refers to a review of the evidence.
In 2009, the NHMRC undertook a systematic review of the literature and revised the 2001 national alcohol guidelines to advise that ‘For women who are pregnant or planning a pregnancy, not drinking is the safest option’ (NHMRC 2009). Advice is also given that the level of risk to the fetus is: highest when there is high, frequent maternal alcohol intake; likely to be low if a woman has consumed only small amounts of alcohol before she knew she was pregnant or during pregnancy; and hard to predict as it is influenced by maternal and fetal characteristics. Women who drank alcohol before they knew they were pregnant or during their pregnancy should be reassured that the majority of babies exposed to alcohol suffer no observable harm. The policy also states that women who find it difficult to decrease their alcohol intake during pregnancy will require support and treatment and it is important that they are referred to the appropriate services (NHMRC 2009).
There appears to be some improvement regarding the consistency of policy recommendation since the implementation of the 2009 NHMRC guidelines. A recent audit of the organisations listed in Table 11.2 found that all government websites (except ACT and TAS) refer to or have links to the NHMRC 2009 recommendations. The ACT Health website refers to the NCG guidelines. Although the NCG guidelines are not consistent with the 2009 NHMRC guidelines, they are currently in the process of being revised. Drug and Alcohol Services within the ACT and TAS were contacted and the representatives noted that abstinence was the safest option during pregnancy and recommended that women be referred to the national guidelines. Some state health organisations refer to both the NHMRC guidelines and the NCG on their websites (e.g. NSW Health). The Victorian Government Health Information page advises women to follow NCG and the Alcohol and other Drugs services in Victoria refer to the NHMRC guidelines. In addition to the information presented in Table 11.2, the Northern Territory Government Department of Health have the 2009 NHMRC guidelines on the Northern Territory Department of Health website.
The medical and nursing organisations presented in Table 11.2 have updated their websites and either quote the NHMRC 2009 guidelines or provide links to the guidelines. An exception is the Australian College of Midwives which refers to NCG. The Royal Australian College of GPs recommends that all patients should be asked about quantity and frequency of alcohol use and those with risk patterns of alcohol consumption should be offered brief intervention.