Background: It is recommended that pregnant women avoid alcohol due to potential harm to the baby. Approximately half of pregnancies in the United Kingdom are not planned, therefore people may not have stopped drinking alcohol prior to realising they are pregnant. Alcohol-free and low-alcohol drinks have become increasingly popular in recent years. However, it is not known what pregnant women think and feel about these drinks and how regularly they are consumed.

Aims: The aims of this project were to understand the attitudes of pregnant women (and those who have recently been pregnant) to alcohol-free and low-alcohol drinks and how this might be linked to alcohol intake before and during pregnancy.

Methods: This project had a mixed-methods approach, with two parts. The first part comprised an online survey, which was developed by the researchers and approved by the funders. The survey included questions about intake, experiences and attitudes towards alcoholic, low-alcohol, and alcohol-free drinks, as well as demographic characteristics and pregnancy history. A combination of open/closed, multiple choice and free text questions were used. People living in the UK who were pregnant or who had recently been pregnant or given birth, were recruited using targeted advertising on social media. For the second part of the project, individual online interviews took place with a subgroup of participants to discuss their experiences and thoughts about alcohol-free and low-alcohol drinks in more detail. These conversations took place with a researcher, lasting approximately 30 minutes. Interviews were transcribed, coded, and analysed thematically.

Results:
Part A: Survey:
• The survey had 2092 respondents, of whom 47.8% (n=1001) were pregnant. The majority were between 25-34 years (55.7%, n=1167) and of White ethnicity (90.0%, n=1881). 
• Approximately 6.1% (n=128) of participants were classified as consuming alcohol at “increasing risk” levels (>15 units per week), prior to pregnancy.
• In preparation for pregnancy, 41.7% (n=873) reduced or abstained from alcohol, but 18.2% (n=831) did not take any specific action to improve their health. In the three months before pregnancy 40.9% (n=857) consumed alcohol-free or low-alcohol drinks.
• 13.5% (n=282) of participants consumed alcohol at some time point during pregnancy, which was more common in those who were in the “increasing risk” category pre pregnancy.
• 71.3% (n=1491) consumed alcohol-free or low-alcohol drinks at some point during pregnancy. This differed by pre pregnancy alcohol consumption category, whereby 69.9% of those in the low-risk category had consumed them during pregnancy, compared to 91.4% in the increasing risk category.
• The most commonly selected reasons for consuming alcohol-free or low-alcohol drinks during pregnancy were “to choose a safer alternative to alcohol” (71.9%, n=1073) to “feel included in social events involving alcohol” (68.8%, n=1026). Those who were in the increasing risk consumption category pre pregnancy were more likely to select “they have a similar appearance to alcohol-containing drinks if I don’t want people to know I’m pregnant” (38.3% vs 19.2% of low-risk group p<0.001).
• The most commonly selected reason for not drinking alcohol-free or low-alcohol drinks during pregnancy was “I prefer a soft drink if I’m not drinking alcohol” (61.1%, n=368).
• Most respondents (77.8%, n=1627) thought consuming alcohol-free drinks (labelled 0% Alcohol By Volume (ABV) during pregnancy was “very acceptable”. This decreased to 10.8% (n=225) for low-alcohol drinks (0.5-1.2% ABV) and to 2.6% (n=55) for consumption of alcoholic drinks during pregnancy.
• Similarly, most participants (79.5%, n=1663) thought that consuming alcohol-free drinks if breastfeeding was very acceptable, with 40.2% (n=840) thinking that consumption of low alcohol drinks was very acceptable and 14.1% (n=295) thinking consumption of alcoholic drinks if breastfeeding was acceptable.
• One fifth (19.6%, n=411) had concerns about the alcohol content and safety of these drinks.
• 56.7% (n=1188) thought there was not enough information available about consumption of alcohol-free and low-alcohol drinks during pregnancy. More than half of participants had not received information about these drinks from any of the listed options (54.5%, n=1141). 21.6% (n=452) had received information from searching on the internet, 12.9% (n=270) from social media, 13.6% (n=285) from advertising and 8.4% (n=176) from their midwife.

Part B: Interviews:
• 20 survey respondents from across the UK took part in individual semi-structured interviews.
• Eleven participants were pregnant at the time of the interview.
• The majority of the participants were in the 25-34 years age bracket.
• In the three months prior to pregnancy, most interview participants consumed 5-6 units of alcohol 2-4 times per month.
• Seven key themes were identified: three themes associated with alcohol and four themes associated with experience and perception of alcohol-free drinks.

Seven key themes were identified: three themes associated with alcohol and four themes associated with experience and perception of alcohol-free drinks. The three themes associated with alcohol were: “social drinking before pregnancy”, “change in preparation for pregnancy” and “avoiding alcohol in pregnancy”. The four themes associated with alcohol-free or low-alcohol drinks were “usefulness and choice”, “attitudes and outside influences”, “barriers to consumption” and “safety and information seeking”.

Women made clear distinctions between the choice to consume alcohol-free drinks compared to regular soft drinks when pregnant, however, most women had never been influenced by outside advertising. The consumption of alcohol-free drinks was also influenced by a perception of increasing popularity, their availability in public spaces and their improved taste: Some women expressed concerns and confusion around the ABV content of alcohol-free drinks and how they were labelled.

Recommendations:
1. Clarity is needed on the safety and suitability of alcohol-free and low-alcohol drinks during pregnancy. Specifically, clarity is needed on those in the 0.05-1.2% ABV category as there are concerns expressed about the threshold levels.
2. Labelling of low-alcohol drinks should be improved, so that they are clearly distinguishable from alcohol-free drinks.
3. Clear guidelines about alcohol-free and low-alcohol drinks during pregnancy and breastfeeding are needed for health care professionals so that consistent advice can be provided.
4. Organisations that provide advice to pregnant and breastfeeding women about alcohol, should also include specific advice about low-alcohol and alcohol-free drinks.

Conclusion: Although alcohol-free and low-alcohol drinks are commonly consumed during pregnancy, some women are concerned about their safety, with little information received from healthcare professionals. Perception and behaviours may vary according to pregnancy history and pre pregnancy alcohol intake. Labelling of alcohol-free and low-alcoholic drinks can be confusing and ABV threshold levels difficult to interpret. More research is needed in relation to safety in pregnancy and when breastfeeding in order that evidenced based guidance can be developed