BACKGROUND Drinking alcohol during pregnancy is associated with Foetal Alcohol Spectrum Disorders (FASD), and women who drink at higher levels are more likely to have a baby with FASD. Public health responses focus on population-level approaches to FASD prevention such as promoting abstinence and alcohol brief interventions. Efforts to better understand and respond to 'high risk' drinking during pregnancy have been largely ignored. This meta-ethnography of qualitative research aims to inform this policy and practice agenda.

METHODS Ten health, social care, and social sciences databases were searched for qualitative studies published since 2000 exploring drinking during pregnancy. Studies that included accounts of women who described themselves, or were diagnosed as, alcohol-dependent during pregnancy, or reported drinking during pregnancy at levels considered by the Word Health Organisation to constitute 'high risk' drinking, were eligible. Noblit and Hare's analytic approach to meta-ethnography was used to synthesise the studies and eMERGe reporting guidance was followed.

RESULTS Nine diverse studies were included. All explored the impact of social norms and relationships, women's knowledge about the risks involved in drinking during pregnancy, the behaviour of women, and the advice they received. Three key themes were identified: drinking is social and relational, knowledge is not enough, and multiple adversities matter. Multiple adversities were interconnected and primarily related to structural inequalities and oppression. The complex needs of women and the wider context in which their drinking occurred were rarely explored or responded to during pregnancy.

CONCLUSION This meta-ethnography provides a more nuanced understanding of the complex dynamics involved in women's 'high risk' drinking during pregnancy, the contexts in which they drink and their unmet needs. These findings can inform future policy and practice responses to 'high risk' drinking during pregnancy. Further research should explore women's experiences in a UK context and consider how services could meet women's needs.