The decisions that are made now have the potential to impact the lives of future generations for the better. With a condition that is preventable and also lifelong, we all have a responsibility to put the health and wellbeing of families first, just as we are doing now as a community.
3.1
Antenatal brain injury caused by alcohol consumption during pregnancy cannot be reversed, and therefore prevention must be the focus of FASD efforts. This chapter examines the role of health professionals, prevention and awareness initiatives, and the issue of alcohol availability and what more can be done to prevent FASD by the government and the alcohol industry.
The role of health professionals
3.2
A range of health professionals play a role in FASD prevention efforts, with midwives, general practitioners (GPs) and specialists involved from pre-conception, confirmation and throughout a woman’s pregnancy to birth.
Early contact with health services
3.3
The first time a woman makes contact with a health service regarding family planning and contraception is an opportune time to discuss the risks of alcohol consumption during pregnancy.
3.4
However, concerns were raised during the inquiry that the opportunity to provide guidance around alcohol consumption is often missed or significantly delayed. It is often the case that the first antenatal visit does not occur until well into a woman’s first trimester.
3.5
In the case of unplanned pregnancies, a woman’s first antenatal visit can also be significantly delayed, by which time alcohol may have been consumed without the woman’s knowledge of her pregnancy.
3.6
The Alcohol and Drug Foundation explained the important role that health professionals play:
As a point of first contact, doctors, midwives and other health care practitioners are in a unique position to play a crucial role in the prevention and identification of FASD. Appropriate screening of prenatal alcohol use should be prioritized and completed for all women to help identify women who may be at risk prior to pregnancy.
Barriers to discussing alcohol consumption
3.7
Research and evaluations conducted as a part of the Women Want to Know project found that health professionals face a range of barriers to discussing alcohol consumption with women, including:
Lack of knowledge of the risks and consequences of alcohol consumption during pregnancy;
fear of negative reactions;
perceived lack of self-efficacy;
lack of skills and tools to intervene;
difficulty discussing alcohol consumption if there were pregnancy complications;
an assumption that alcohol would be discussed by another health professional (where a woman sees multiple providers, such as a GP and a midwife); and
a desire to provide reassurance where alcohol has been consumed during before pregnancy.
A lack of understanding of the risks of alcohol consumption during pregnancy
3.8
The Women Want to Know project revealed that, despite a level of awareness of FASD, there are prevailing myths that persist amongst health professionals.
3.9
This included the view that there was a ‘safe time’ to drink during pregnancy, a ‘safe amount’ of alcohol that could be consumed, and a ‘safe type’ of alcohol, that is, that some alcohol has a worse impact on the developing fetus.
3.10
Studies have shown that although health professionals are broadly aware of the guidance that women should completely abstain from alcohol during pregnancy, there is a lack of understanding of the negative consequences, and as a result women are receiving poor advice.
3.11
According to a study of midwives in South Australia, the specific effects of alcohol consumption during pregnancy were not well understood amongst participants:
… when it came to attitudes towards alcohol consumption during pregnancy several midwives expressed views divergent from the Alcohol Guidelines. They felt that small amounts of alcohol were unlikely to be harmful and some advised women that if they wanted an occasional drink, that would be acceptable.
3.12
The mother of a teenage boy with FASD described to the committee how the combined advice of midwives, GPs and the national alcohol guidelines, during her pregnancy, suggested that drinking in moderation was safe:
I visited the GP and he reassured me that I shouldn't be concerned and that was a massive relief. I read the guidelines from the National Health and Medical Research Council—this is prior to 2009. It was deemed safe to drink two standard drinks per day and no more than 10 per week. I asked my midwife about alcohol in pregnancy, and 'The odd one or two won't hurt,' was the reply. To give you an idea, I would drink one weak coffee a week, I would wash my salad and I would avoid soft cheese and pate for fear of causing harm to my developing baby. However, I still remember very clearly standing in my kitchen on a Friday night, as my treat, measuring one unit of wine.
Stigma
3.13
The Australian Medical Association noted that clinicians are generally reluctant to discuss FASD with their patients because of the perceived stigma associated with consuming alcohol during pregnancy.
3.14
Professor Elizabeth Elliott of the Royal Australasian College of Physicians explained:
There ha[ve] been studies done specifically on this in Australia. Doctors tell us they are afraid to ask because they don't want to make the patient anxious and upset. They're worried about disrupting the doctor-patient relationship. Also, they don't know how to ask in a meaningful way. They don't know what questions to use, and, if they do find out that the woman is drinking alcohol, they don't necessarily know what to do about it and where to refer them.
3.15
The National Organisation for Fetal Alcohol Spectrum Disorders (NOFASD) told the committee that the issue of stigma is complex and also affects how a pregnant woman will engage with her health provider:
… as one birth mother said the stigma began with the unplanned pregnancy. Women at risk of an alcohol exposed pregnancy are potentially already experienced at avoiding contact with services because of the stigma associated with their alcohol use. Stigma, fear and shame will further drive patients in need away from services.
3.16
According to the National Drug Research Institute, women overwhelmingly want health professionals to inform them about drinking during pregnancy and the risk of FASD, however, there is a hesitancy to do so due to the perceived sensitivity of the issue:
This reluctance among the health profession to provide appropriate advice and information indicates the need for effective training so the needs of women and their families are met.
Health professional’s personal views and assumptions
3.17
Another barrier to women getting accurate, timely and appropriate advice on alcohol and pregnancy appears to be the belief held by health professionals that most women already know to reduce their consumption or to abstain from alcohol and therefore do not require advice.
3.18
Whether or not a health practitioner will talk about alcohol consumption during pregnancy with a patient is also influenced by assumptions about a woman’s social and economic circumstances, and in particular, the belief that women of lower socio-economic status are more likely to need advice.
3.19
Research has found that older women in the higher socio-economic group were the most likely to continue drinking after finding out they were pregnant and yet they were the least likely to receive appropriate medical advice.
3.20
A 2019 NSW study showed that women were more likely to receive advice and support if they had not gone to university, did not reside in an advantaged area, if it was their first pregnancy, and if they were from a regional/rural service location.
3.21
Health practitioners report a reluctance to talk about FASD with patients displaying higher, problematic levels of alcohol consumption, as there they were assumed to be drinking in extenuating circumstances ‘beyond the capacity of health professionals to address’, such as socio-economic disadvantage, domestic violence and/or other substance use.
Routine screening and brief intervention
3.22
International guidelines recommend screening and brief intervention to ensure that all women are asked about their alcohol use and that women who are drinking are offered advice.
3.23
Screening involves asking questions to assist in assessing alcohol use and enables brief interventions which are aimed at identifying real or potential alcohol problems and motivating a person to do something about it.
3.24
The Deeble Institute for Health Policy Research suggested that screening assessments should be used to provide tailored feedback to women about their alcohol use and enable referrals to appropriate supports and/or treatment services as required. In addition, screening should be underpinned by trauma-informed, person-centred and culturally secure care.
3.25
The Foundation for Alcohol Research and Education (FARE) explained how routine screening and brief interventions can help inform and educate women:
Questions about alcohol consumption should be asked along with other lifestyle questions about diet, exercise and whether the person smokes or not. These answers can give a better understanding of a person’s health and allow for education on the risks associated with alcohol to take place in a non-judgemental manner.
3.26
However, inquiry participants noted concerns that health professionals are not routinely asking women about their alcohol use during pregnancy or providing adequate medical advice. FARE noted that there is ‘no consistent implementation’ of screening and brief intervention in maternity care in Australia.
3.27
Research suggests that only 45 per cent of health professionals routinely asked about a woman’s alcohol use, and only 25 per cent provided information about the implications of drinking alcohol, suggesting that health professionals are acting on a presumption that a woman has stopped drinking alcohol.
3.28
NOFASD reported similar statistics, with 47 per cent of women that participated in their online survey reporting that a GP had never spoken to them about alcohol use and pregnancy, and only 14 per cent reporting that they had received information before becoming pregnant.
Contraception and family planning advice
3.29
The committee heard that advice on contraception, sexual health and pregnancy is not routinely provided by health professionals, even though women who drink alcohol during pregnancy are less likely to have planned the pregnancy.
3.30
FARE told the committee that prevention strategies should include interventions that target both pre-pregnancy contraception and alcohol consumption before and during pregnancy.
3.31
According to the Royal Australian College of General Practitioners all women who are pregnant or planning a pregnancy should be subject to screening, and referrals and advice provided as necessary, including contraceptive advice to reduce unplanned pregnancies.
Use of the validated screening tool (AUDIT-C)
3.32
The Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) tool is a validated screening tool used to collect information about consumption of alcohol during pregnancy, and is recommended by the Australian guide to the diagnosis of FASD.
3.33
The University of Queensland suggested that the AUDIT-C tool should be used in all relevant clinical settings to standardise screening and the recording of antenatal alcohol use. However, evidence put to the inquiry suggests that the AUDIT-C tool, although well received and used in some jurisdictions and across disciplines, it is not routinely used throughout Australia.
3.34
Inquiry participants outlined efforts to embed the AUDIT-C tool into templates and health records to help prompt routine discussions with pregnant women.
3.35
For example, a project is underway in New South Wales (the Hunter New England project) to embed the AUDIT-C tool into e-maternity records to enable maternity services to ask about alcohol in a standardised way and provide advice and referral according to the estimated level of risk to the unborn child.
3.36
Professor Elizabeth Elliott of the Royal Australasian College of Physicians told the committee that initiative prompts the obstetrician or the midwife to ask standardised questions and then enables further action:
But what's really important is that it then tells them what risk category that woman is in and where they should seek help for that woman or refer that woman for treatment.
3.37
Dr Susan Adams of the Royal Australasian College of Surgeons told the committee that once questions about alcohol use, or a form of screening, becomes routine it will become easier for health practitioners to discuss maternal alcohol consumption. She observed that ‘it needs to become the norm’.
3.38
The committee also heard that the AUDIT-C tool can help collect standardised data. However, greater awareness and training in the tool would be required and there may be adaptations needed locally, or regionally, to ensure implementation is optimised.
How to talk to women to reduce the risk of underreporting
3.39
The committee heard that the approach to screening and brief intervention must be tailored to avoid potential underreporting, with research showing that the way a conversation takes place between a health professional and a woman will impact on disclosure rates of alcohol use during pregnancy.
3.40
The Women Want to Know project suggests that advice should be based on an assessment of a woman’s alcohol consumption before and during their pregnancy and that it is tailored to individual circumstances. Accordingly, consideration should be given to a woman’s previous pregnancies, levels of stress and experiences of current or previous trauma and abuse.
Continuity of care
3.41
The committee heard support for continuity of midwifery care as a model for supporting women to discuss alcohol consumption during pregnancy and make lifestyle and behaviour changes.
3.42
The Australian College of Midwives (ACM) told the committee that through the continuity of care model, midwives can develop an ongoing and trusted relationship with pregnant women which enables a rich dialogue helping a midwife to identify and help the women self-manage many pregnancy issues and risks.
3.43
Despite the recognition of the improved outcomes for women and their baby, however, the continuity of care model is not universally available in Australia.
Building capacity in health care professionals
3.44
The committee heard that, a lack of understanding of referral, diagnosis and support strategies amongst health care professionals is the ‘most significant barrier’ to women receiving appropriate and timely information.
3.45
The ACM submitted that there are several studies showing that health care professionals have insufficient training and education with respect to the effects of alcohol and FASD.
3.46
Dr Chinar Goel of the Royal Australian and New Zealand College of Psychiatrists suggested that FASD is not sufficiently covered in medical education and training and therefore clinicians do not think of FASD as their first diagnosis:
It isn't much covered in the medical education or in the training aspect. It wasn't covered when I was studying at my medical school, so obviously, if clinicians haven't been made aware of this, it's not something at the forefront of their mind.
Training needs
3.47
Inquiry participants were broadly supportive of further training and awareness initiatives amongst health care professionals involved in antenatal care.
3.48
For example, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) suggested clinicians must be educated in interviewing and intervention regarding alcohol use in childbearing-aged women with an aim to reduce alcohol use and increase effective contraception.
3.49
Dr Vijay Roach, President of RANZCOG, explained:
We need to be taught not only about the importance of alcohol but also how to talk about it, what to ask and, importantly, how to follow up. The point was made before that we need structures in place to support us. We just can't be asked to talk to women about this issue without then having the opportunity to follow it up. Communication needs to be culturally sensitive and cross-cultural.
3.50
The committee heard that to build the capacity of health professionals to effectively screen and provide advice to pregnant women, specific practitioners should be targeted. This includes GPs, gynaecologists, obstetricians, midwives, child health nurses and paediatricians.
3.51
The Deeble Institute for Health Policy Research observed that professional bodies play an important role, and should partner with research bodies, tertiary training institutions, and service providers to identify capacity building initiatives.
3.52
Ms Sarah Ward of FARE commented that any training efforts must be supported by a broader education and awareness campaign:
… we have not consistently informed health professionals and women about alcohol consumption, which comes back to the need for a national campaign and national consistency on the issue … We all have a part to play in helping health professionals...
Training resources
3.53
Evidence before the committee points to several successful initiatives that have helped raise health professionals’ knowledge and confidence talking about alcohol during pregnancy.
3.54
For example, training provided as a part of the Hunter New England study, discussed above, has resulted in an increase in nurses and doctors knowledge and confidence in asking, advising and making referrals regarding alcohol use in pregnancy.
3.55
As a Women Want to Know project, a range of resources have been developed to support health practitioners discuss alcohol consumption during pregnancy. This includes videos, leaflets, printed and online resources, and accredited online training courses.
3.56
However, an evaluation of the Women Want to Know project found ‘mixed success’ in attempts at training and awareness initiatives amongst health professionals. Barriers included awareness of available training, the need for incentives other than continuing professional development, and a desire for more up-to-date evidence.
3.57
The Deeble Institute for Health Policy Research suggested that, based on these findings, any capacity-building initiatives must be developed in consultation with health professionals, tertiary training programs, and professional bodies, so that dissemination is supported and engagement and completion rates are maximised.
3.58
The committee heard the Commonwealth has awarded FARE a multi-year grant over 2019–20 to 2022–23 to deliver best-practice resources for priority groups, including resources and screening tools for multidisciplinary teams to support and educate people in high-risk groups.
Tertiary training and continuous professional development
3.59
Evidence to the committee stressed the importance of targeting education efforts at both undergraduate studies and continuous professional development.
3.60
One inquiry participant suggested that there is limited specific information on FASD in undergraduate programs, including speech pathology, psychology, occupational therapy, physiotherapy, social work, nursing and medicine.
3.61
There was support for strengthening the delivery of FASD coursework in undergraduate, postgraduate and pre-registration programs, including through the delivery of specialist programs.
3.62
It was further suggested that FASD should be essential coursework for undergraduate students in in all health-related, justice-related and welfare-related disciplines.
3.63
In addition, that the FASD curriculum, particularly in primary health care undergraduate courses, should be more thorough and taught as a multidisciplinary collaborative practice.
Australian Clinical Practice Guidelines for pregnancy care
3.64
Ms Sarah Ward of FARE told the committee that the Clinical Practice Guidelines: Pregnancy care still refers to out-of-date alcohol guidelines from 2001 and has been slow to incorporate current FASD tools and information:
There is some information at the start of that chapter that refers to AUDIT-C; the FASD diagnostic tool; and the Women Want to Know resources. It did get updated a small amount after we requested it, but it is still considerably out of date.
3.65
In its submission to the committee, FARE expressed concern that the failure to update the clinical guidance sends a broader message about that national commitment to FASD prevention:
This omission in updating the Alcohol chapter suggests that alcohol harm is not forefront of mind and that, despite significant achievements, the issue of alcohol and pregnancy is still under-prioritised by Australian governments and health officials.
Awareness and education initiatives
Commonwealth programs and funding
3.66
The Australian Government has funded several FASD awareness raising and education activities, including:
The Women Want to Know project, discussed above, which aims to improve awareness of FASD information and resources to support health professionals to discuss and raise awareness about alcohol consumption during pregnant with pregnant women;
the Pregnant Pause activity which aims to raise awareness of drinking alcohol during pregnancy, whilst breastfeeding or when planning a pregnancy; and
related social media awareness campaigns, including discrete projects by bodies such as NOFASD.
3.67
FASD Hub Australia, which is also funded by the Australian Government, was established in 2017 as a source of information and resources for health practitioners and the public. It includes a website with open access materials, and telephone and online counselling services for individuals and families.
3.68
Commonwealth funding has also been provided for projects aimed at preventing FASD in First Nations communities. This includes tailored FASD resources, and health promotion messages translated into six languages and broadcast through the National Indigenous Radio Service for three months during the AFL season.
Effectiveness of existing awareness and education initiatives
3.69
Despite the range of existing initiatives, awareness of FASD and the risks of alcohol consumption during pregnancy remain low in the general population and there are clear gaps in understanding across the health workforce contributing to inconsistent information being provided to women.
3.70
The committee heard support for initiatives like Pregnant Pause as a community-focused initiative which encourages women to stop drinking during pregnancy and asks partners, friends and families to pledge to go alcohol-free in support.
3.71
However, the Public Health Association of Australia told the committee that existing awareness campaigns are not sufficiently promoted:
Various campaigns with the aim to promote the message of limiting alcohol during pregnancy and breastfeeding including Women Want to Know and Pregnant Pause are not well-established in the Australian media or online platforms.
3.72
FARE, which was initially funded to run the Pregnant Pause campaign in the ACT, and later across Australia, recognised its limitations as a national campaign:
Unfortunately, the impact of Pregnant Pause at a national level has been limited. Funding only provided for targeting of three eastern-state cities, and the campaign relied on social media.
3.73
FARE suggested that the Pregnant Pause campaign should be further expanded:
To be holistic, the target group of Pregnant Pause should be expanded to include the health professions supporting women, such as professionals providing family planning and contraceptive advice, GPs, pharmacists, obstetricians, and gynaecologists. It could also expand opportunities for the message about alcohol-free pregnancies through universities, childcare groups and other places where women frequent.
3.74
According to FASD Research Australia, FASD Hub is widely used as a central repository of FASD information and resources. However the committee heard that its ongoing role as a national resource remains subject to Commonwealth grants and that it needs adequate long term funding.
Messaging on the risks of alcohol during pregnancy
3.75
The committee heard that the messaging around the risks of consuming alcohol during pregnancy has been ineffective.
3.76
The ACM submitted that women are receiving mixed messages about the risks of alcohol consumption during pregnancy from their peers and health professionals:
Messaging around the implications of consuming alcohol during pregnancy are often confusing, unclear and inconsistent as is the information that is shared both professionally and socially.
3.77
The Public Health Association of Australia was critical of public health messaging which talked about alcohol consumption during pregnancy in terms of being ‘frequent and heavy’. It said that these terms are an ineffective way to communicate the message that no alcohol should be consumed during pregnancy.
Empowering not stigmatising
3.78
Several inquiry participants suggested that messaging in any FASD awareness campaign needs to be empowering for women, not further stigmatising.
3.79
The committee heard that alarmist messages are ineffective, can negatively impact on mental health, and lead to uninformed decisions such as requests for termination of pregnancy.
3.80
One witness commented on the stress and fear associated with the range of screening undertaken during pregnancy which can result in ‘antenatal scare’.
3.81
Dr Vijay Roach, President of RANZCOG, outlined the importance of messaging that is supportive, educative and clear that responsibility is shared by the broader community:
… women already carry the burden of pregnancy and childrearing and the sorts of social pressures that go with that. There's enormous pressure to be a perfect mother, but no-one is perfect. I think that our premise should always be that a woman loves and cares for her child and that she will do everything that she can to protect that child. Punitive measures don't work. They're counterproductive. Therefore, our message should always be one of support, education and understanding. Ultimately, what we really need to underpin this is a whole-of-society cultural change.
3.82
The committee was told that overseas, empowering public health campaigns have seen positive results.
3.83
FARE gave the example of a national campaign in Norway which resulted in a 20 per cent reduction in the number of people in the general public who believed pregnant women could consume ‘some alcohol with dinner’:
The Norwegian campaign is an example of how multifaceted, consumer-tested campaigns that focus on empowering women to not consume alcohol during pregnancy, can have a positive impact on attitudes towards alcohol use in pregnancy.
Promoting the national alcohol guidelines
3.84
The committee heard concerns that the general public has a low level of awareness of the national alcohol guidelines.
3.85
FARE told the inquiry that the guidelines ‘zero alcohol’ recommendation for women who are pregnant, planning a pregnancy or breastfeeding, is not well known, despite this recommendation having been the same for ten years.
3.86
Community-wide polling commissioned by FARE shows that awareness of the ‘zero alcohol’ guidelines is slowly increasing over time, with 78 per cent of men and women aware of it in 2019, up from 67 per cent in 2012.
3.87
FARE submitted that there is a limited awareness of the national alcohol guidelines due to a lack of promotion, and noted that, to date, there has been no national campaign to promote the guidelines to the general public.
Industry-funded initiatives
3.88
DrinkWise, an industry-funded organisation, has implemented a FASD awareness-raising campaign.
3.89
The campaign is aimed at creating greater awareness amongst Australians of FASD and the risks of drinking while pregnant, planning a pregnancy and breastfeeding. DrinkWise initiatives include resources for GP waiting rooms, online materials, and school and community programs.
3.90
However, inquiry participants suggested that DrinkWise is not an appropriate vehicle for alcohol education and that industry education consistently underperforms.
3.91
FARE noted that the language used in some DrinkWise campaigns has ‘suggested that it is unknown if alcohol is safe during pregnancy’. Although DrinkWise has since revised the material following complaints, out-of-date material still features in clinics around Australia.
National awareness campaign
3.92
Witnesses called for a national awareness campaign to raise the level of community awareness of the risks of alcohol consumption during pregnancy.
3.93
In the course of the inquiry, the Australian Government announced an additional $25 million in funding for a national awareness campaign for pregnancy and breastfeeding women. A grant was awarded to FARE to deliver the project from July 2020 to June 2023.
3.94
This campaign, the Fetal Alcohol Spectrum Disorder (FASD): National Awareness Campaign for Pregnancy and Breastfeeding Women, will be informed by consultation and subject to ongoing evaluation, and delivered in streams to four distinct target audiences:
health professionals, by August 2021;
general awareness, by September 2021;
at-risk groups, by March 2022; and
First Nations communities, by March 2022.
3.95
According to the CEO of FARE, Ms Caterina Giorgi, the national campaign will be the largest campaign of its kind anywhere in the world and will provide an opportunity to communicate ‘clear and consistent messages about alcoholic products, pregnancy and breastfeeding with the broader community and people who are most at risk’.
3.96
In addition, NOFASD was also provided Australian Government funding to deliver a COVID-19 alcohol and pregnancy campaign addressing increased alcohol consumption leading to unplanned alcohol-exposed FASD pregnancies during the COVID-19 pandemic.
Complementary activities
3.97
The committee heard that any national awareness campaign must be supported by targeted medical information to explain the rationale.
3.98
It was suggested that any campaign must be multifaceted, with one aspect focusing on women and the general public, and another aspect focusing on health professionals.
3.99
The Australian College of Midwives explained:
… where woman sees a bus stop poster with a clear message to not drink during pregnancy and that message is supported by the midwife/GP/Obstetrician and family and friends giving similar messages.
Targeting at-risk groups
3.100
FASD Research Australia told the committee that in designing an evidence-based awareness campaign, it is necessary to identify population subgroups based on factors such as behaviour, risk and attitudes towards alcohol:
This will allow program developers and researchers to understand what awareness or health promotion campaigns should look like, and what they should set out to achieve. Without this first step, a campaign is unlikely to change attitudes or behaviour. Robust formative work and evaluation is crucial.
3.101
The committee also heard that any health advice must be tailored to a woman’s individual and community contexts:
… blanket abstinence messages are often ineffective because the decision-making around alcohol use by pregnant women is influenced by their individual understanding and conceptualising of its potential harms. In addition, women’s wider social and cultural environment impacts on their ability to abstain.
3.102
Ms Prue Walker, FASD consultant and Service Coordinator at VicFAS, stressed the importance of campaigns for the broader community complementing any targeted initiatives:
FASD is an issue that affects the whole community, and we need to ensure that this is conveyed in our messaging around FASD. Finding a balance between community wide strategies and targeted interventions is important.
3.103
In the context of its planning for a national education campaign, FARE outlined the importance of development work to ensure messaging has the greatest impact on influencing behaviour change and does not contribute to stigma relating to FASD and the use of alcohol products in pregnancy:
… we're really carefully engaging with a range of groups across the women's sector, the disability sector, the health professionals sector and people with lived experience and are developing a really comprehensive stakeholder engagement framework to make sure that we can get all the information we need to make this campaign as effective as it can be.
A focus on pre-conception
3.104
Inquiry participants suggested that any public education campaign must target women of childbearing age seeking family planning and contraception advice.
3.105
The World Health Organization’s Prevention of harm caused by alcohol exposure during pregnancy notes that interventions that target contraception and alcohol consumption are effective in reducing the risk of women drinking alcohol during pregnancy.
3.106
NOFASD told the committee that this group requires a different approach, ‘through different communication channels’ in order to increase the success of prevention initiatives.
3.107
In New Zealand, the ‘Pre-Testie Bestie’ campaign focuses on empowering women’s female peers to encourage them to stop drinking alcohol if there is any chance that they could be pregnant. At the March 2021 public hearing, FARE noted some concerns, however, about the effectiveness of this campaign, observing that overall there is a lack of evidence about effective campaigns and a need for careful consultation.
Programs in schools
3.108
Several inquiry participants suggested that the secondary school curriculum should include information about the risks of alcohol consumption during pregnancy.
3.109
The Alcohol and Drug Foundation told the committee that education about the risk of drinking before and after conception should be a ‘mandatory aspect of the secondary school health education curriculum’ along with education about sex, alcohol and other drug use.
3.110
In 2018, the Australian Government provided DrinkWise with funding to produce education videos for students about FASD, peer pressure and the importance of not drinking until they are 18.
3.111
DrinkWise told the committee that the videos have been made available to nearly 200,000 state secondary school students as part of alcohol and other drugs curriculum.
Reducing community-level alcohol consumption
3.112
The committee heard that FASD prevention must fundamentally address the role of community-level consumption and alcohol availability.
3.113
This is particularly important given research showing that a woman’s alcohol consumption during pregnancy is influenced by levels of pre-pregnancy drinking.
Population-level responses
3.114
FARE told the committee that population-level responses to alcohol availability represent ‘best buys’ to reduce alcohol-related harm. These include increasing excise tax on alcohol beverages, regulating alcohol marketing, and enacting and enforcing physical restrictions on the availability of alcohol.
3.115
The Western Australia Network of Alcohol and other Drug Agencies submitted that population-level restrictions are one of the most effective strategies to reduce alcohol-associated harm:
These approaches recognise the need to provide an equitable policy response that addresses whole-of-community and environmental factors, rather than just focussing on an individual’s behaviour.
Tax and price reform
3.116
The committee heard that the low price of alcohol in Australia contributes to higher levels of alcohol consumption, resulting in higher levels of alcohol-related harm.
3.117
It was suggested that the current alcohol tax system contributes to alcohol harm by incentivising the sale of cheap wine and wine-based products.
3.118
The committee heard that tax and price reform measures could contribute to reducing alcohol harm, for example, through changes to the Wine Equalisation Tax:
The Wine Equalisation Tax, along with its associated rebate, should be replaced with a volumetric tax set at a rate between beer and spirits. To date, at least 13 government and parliamentary reviews have concluded that wine should be taxed on a volumetric basis.
3.119
The National Alliance for Action on Alcohol also suggested that to complement tax reform, states and territories have the power to introduce a minimum unit price and put controls on the use of discounts.
3.120
The Northern Territory (NT) Government introduced a minimum unit price in 2017. Inquiry participants told the committee that the changes have contributed to reductions in alcohol-related violence, intimate partner violence and emergency department presentations. The NT Government’s alcohol reforms are discussed in further detail in Chapter 6.
3.121
The National alcohol strategy 2019–2028, discussed further below, suggests a range of pricing and taxation reforms to reduce risky alcohol consumption. This includes:
the introduction of a minimum floor price for alcohol;
taxation reforms such as volumetric taxation; and
direct revenue from alcohol taxation is to be put towards preventative health activities and alcohol and other drug treatment services.
Alcohol marketing
3.122
The committee heard that the way women of child-bearing age are targeted by alcohol marketing is concerning:
A really insidious strategy that's been really prevalent recently is marketing to women through social media, including using social media influencers such as mum bloggers. Women then often share this marketing, such as 'wine mum' memes, which promote alcohol as a coping mechanism. We've seen a lot of this recently during COVID-19 restrictions.
3.123
Concerns were also raised around online marketing, with the data from retailer memberships and individual’s online purchasing history, being used to micro-target alcohol advertising.
3.124
FARE commented that during the COVID-19 pandemic, their analysis of Facebook and Instagram during a one-hour period showed an alcohol ad every 35 seconds. Almost a quarter of those ads referenced the pandemic.
3.125
Ms Caterina Giorgi, Chief Executive Officer of FARE, told the committee that further regulation is needed to address this new and emerging issue:
… addressing this involves looking at regulatory structures across a range of different platforms. That's looking at the way that data is collected and used and also looking at the responsibility of platforms themselves and the responsibility of companies.
3.126
Several inquiry participants criticised attempts by the industry to self-regulate alcohol advertising. According to the National Alliance for Action on Alcohol:
The obvious conflicts of interest mean the industry-managed processes could never restrict alcohol marketing in a genuinely effective manner. A new approach to controlling alcohol marketing is needed to prioritise the protection of young people and other vulnerable groups.
3.127
Ms Sarah Jackson of Cancer Council Victoria argued for comprehensive legislation regulating alcohol advertising:
It's really key that there's comprehensive legislation regulating alcohol advertising, as there is for tobacco advertising that's been in place for 20 years. We really have no legislation that regulates alcohol advertising in the country at the moment. We have a regulatory code at the federal level, but there are big loopholes in that code.
3.128
Alcohol Change Victoria outlined explained that some of the loopholes in the co-regulatory Commercial Television Industry Code of Practice currently enable exposure of children to alcohol advertising, including during sporting events.
3.129
The National alcohol strategy 2019–2028 outlines the need to extend the single national advertising code to provide consistent protection of exposure to minors regardless of programming. It also outlines a set of shared measures to reduce promotions and discounts for low priced alcohol.
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The Department of Health told the committee that the national alcohol strategy has sufficient flexibility to enable all jurisdictions to target emerging issues in alcohol marketing as they arise over time.
Pregnancy warning labels
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Labelling on alcohol products and packaging was introduced in 2011 on a voluntary basis by the alcohol industry.
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In October 2018, the Australia and New Zealand Ministerial Forum on Food Regulation agreed on a mandatory labelling standard for pregnancy warning labels on packaged alcoholic beverages should be developed.
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In July 2020, the forum agreed upon a draft standard for pregnancy warning labels, and recommitted to mandatory labels on alcohol and packaging.
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The committee heard frustration at the time it has taken to achieve a mandatory pregnancy warning label.
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Inquiry participants advocated for a national education and awareness campaign to support the rollout of the pregnancy warning labels.
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FARE recommended that, immediately prior to the mandatory application of the pregnancy warning label, a comprehensive public education campaign should be implemented to inform consumers about the changes.
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The alcohol industry has three years from 31 July 2020 to comply with the new requirements. The committee heard that some smaller alcohol companies have already started to apply the warning label, and that larger companies have been encouraged to do the same ahead of the due date.
A comprehensive national prevention strategy
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The committee heard that Australia needs an overarching prevention program and that this must be sufficiently funded in order to be effective.
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The committee heard that current efforts have involved funding and initiatives that are on a small scale, piecemeal and inconsistent. FARE argued that ‘with such restrained commitment, these activities are not able to reach their full potential’.
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The Australian College of Midwives argues that prevention strategies are most effective when they are approached from a collaborative, multifactorial, widespread approach. This includes legislative changes, access to alcohol and labelling, community and women’s awareness, diagnosis, targeted education and quality care during pregnancy.
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The four-part prevention framework implemented by the Public Health Agency of Canada was widely recognised by inquiry participants as best practice. It promotes:
broad awareness-raising and health promotion through mass media;
discussion about FASD/alcohol with all women of childbearing age and their families;
antenatal support for pregnant women with alcohol and other social/health issues; and
postnatal support for new mums and support for child assessment and development.
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Professor Doug Shelton of the Gold Coast Hospital and Health Service explained the strengths of the Canadian model:
It's multifaceted and involves public health campaigns and the provision of direct services, particularly in midwifery and maternity care, so that prenatal alcohol exposure can be picked up very early, if not prior to the pregnancy, and services can be offered to encourage the woman to cease or decrease her alcohol consumption. Then really it goes the full circle to the provision of care to women postnatally, including mental health and support with any other stressors and issues they may have in their lives.
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FARE commented that this model has been implemented in parts of Australia by clinicians and researchers but has not yet been adopted by the government as a national approach. It noted that:
For a national prevention program to be effective, clear responsibilities are required between federal, state and regional level governments to be implemented within specified timeframes. Adequate funding needs to be provided for such a program, for which principles already exist.
Committee view
National public education campaign
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The committee heard overwhelming evidence of the need for a national public education campaign over the course of this inquiry. The Australian Government’s announcement that it is funding a national campaign from July 2020 to June 2023 is welcome news. However, given the scale of the effort required to build public awareness and understanding of FASD and alcohol-related harms in the broader community, the committee is of the view that government must invest in this activity over the life of the National Fetal Alcohol Spectrum Disorder (FASD) strategic action plan 2018–2028.
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The committee recommends that the Australian Government develop a broader strategy and budget for a national public education campaign over the life of the National Fetal Alcohol Spectrum Disorder (FASD) strategic action plan 2018–2028.
FASD education for schools
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The committee considers that education about the risks of maternal alcohol consumption, and FASD, must be included in secondary school curriculums as a part of sex education. This activity should complement the efforts of a national public education campaign.
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The committee recommends that the Department of Health fund the development of FASD education resources to be used in secondary school curriculums.
Overcoming barriers experienced by health professionals
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The committee is deeply concerned by evidence suggesting that the risks of alcohol consumption during pregnancy are not routinely raised with pregnant women and women of child-bearing age by health professionals. The committee is also concerned that the 2020 Australian guidelines to reduce health risks from drinking alcohol are not reflected in current clinical guidance and not well understood by health professionals.
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The committee recommends that the Australian Clinical Practice Guidelines: Pregnancy care are updated as a matter of priority to ensure consistency with the 2020 Australian guidelines to reduce health risks from drinking alcohol.
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There is a clear need to further and more thoroughly teach FASD, and screening and brief intervention practices, in tertiary training programs at both undergraduate and postgraduate levels. The committee encourages partnerships between universities, training bodies, professional bodies, research bodies and service providers to identify and address the current gaps.
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The committee recommends that the medical profession, including the various medical colleges, acknowledge the critical role they play in education and awareness-raising of the dangers of consumption of alcohol for both women and men, particularly as it relates to consumption in relation to pregnancy.
Routine screening
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The committee commends the efforts to improve screening and brief intervention practices, including embedding standardised screening tools into health systems, like that being trialled in the Hunter New England study. Initiatives like this should be carefully evaluated, with a view to developing a universal and best-practice screening and brief intervention model for broader implementation.
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The committee notes the Australian Government’s recent funding allocation for the development of best-practice resources for health professionals, including screening tools for treating at-risk groups. Whilst this is a valuable activity, the committee considers further steps are needed to embed educational resources and screening tools into routine practice in antenatal care.
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The committee recommends that the Australian Government provide funding for professional development training for all health professionals involved in antenatal care, in order to embed routine FASD screening practices and tools, including AUDIT-C.
Reducing community-level alcohol consumption
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The committee is of the view that prevention efforts must fundamentally aim to shift societal attitudes and behaviour around alcohol consumption in the broader Australian community. The long-awaited national alcohol strategy provides an opportunity for Australia to address alcohol-related harm in a meaningful way. At the Commonwealth level, marketing, pricing and taxation reforms should be considered as a priority to address the availability of cheap alcohol and reduce risky alcohol consumption.
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The committee recommends that the Australian Government implement as a matter of priority marketing, pricing and taxation reforms as set out in the National alcohol strategy 2019–2028.
Mandatory pregnancy warning labels
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The introduction of pregnancy warning labels represents a significant step forward in reducing alcohol-related harm, and specifically, the risk of FASD. The committee encourages the alcohol industry to respond quickly to mandatory labelling requirements ahead of the proposed introduction date. The committee is of the view that a specific awareness campaign is needed to promote and explain the new pregnancy warning labels to the community.
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The committee recommends that the Australian Government run a specific public education campaign with respect to the roll-out of mandatory pregnancy warning labels.
A comprehensive national prevention strategy
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The committee acknowledges the strengthened national priority on FASD prevention activities as outlined in both the National alcohol strategy 2019–2028 and the National FASD strategic action plan 2018–2028. The committee commends recent funding announcements by the Australian Government, which have included several key preventative measures announced in the course of this inquiry, under both national strategies.
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Despite this investment, the committee holds concerns that the national approach to FASD prevention will continue to be fragmented, piecemeal and underfunded into the future. This is an unacceptable risk, given the significant social and economic costs of FASD outlined in the previous chapter. Therefore, the committee is of the view that a single comprehensive national prevention strategy and funding allocation must be implemented by the Australian Government.
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The prevention strategy should provide the blueprint for a comprehensive and collaborative approach to FASD prevention by the Australian Government and state and territory governments. It should be consistent with, and build upon, the prevention objectives outlined in the National alcohol strategy 2019–2028 and the National FASD strategic action plan 2018–2028. Importantly, it must be fully costed and funded, with responsibilities allocated between the Commonwealth, states and territories.
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The committee recommends that the Australian Government fund a National Prevention Strategy to be developed and delivered in collaboration with State and Territory Governments.