Informal approach key to tackling drinking in pregnancy

Health professionals should adopt a "conversational approach" and focus on building trust when discussing alcohol consumption with pregnant women, midwives have told researchers.

It is estimated that more than 40 percent of women in the UK consume alcohol during pregnancy – one of the highest rates in Europe – despite there being no known safe level in terms of the health of their unborn child.

International guidelines recommend the use of alcohol screening and brief interventions (SBIs) in antenatal care to identify drinking and offer support to women to reduce the risks. Typically, SBI involves a short conversation with a midwife, whilst women who are drinking more heavily can be offered specialist support. However, few studies have investigated their implementation.

The new study – by the Universities of Stirling and Edinburgh – considered a national programme introduced in Scotland, which involves midwives delivering SBI. It found that a “flexible, conversational approach” was felt to be more successful in encouraging honest disclosure of drinking habits by pregnant women. This contrasts with previous research that has recommended using formal screening tools, such as structured questionnaires.

Dr Niamh Fitzgerald, of Stirling’s Institute for Social Marketing, led the study. She said: “Midwives used several strategies to facilitate honest disclosures, including taking a positive tone in conversations and exploring drinking habits prior to pregnancy or prior to when women realised they were pregnant. It was felt that these approaches helped build a trusting relationship between pregnant women and midwives and improved disclosure rates.

“However, we also heard reports that, in some cases where there had been initial improvements, the number of women disclosing drinking proceeded to decline. This trend coincided with the inclusion of additional, separate questions about parenting capacity – raising the possibility that other questions, asked at the same time as alcohol screening, may impact on disclosure rates.”

Dr Niamh Fitzgerald has led the new research, alongside colleagues from the University of Edinburgh.

On several occasions, midwives found that reported alcohol use elicited through standard questions was lower than expected given the known levels of alcohol use in their local area.

Dr Fitzgerald added: “It was clear that implementation leaders felt that the use of screening questions had to be flexible and not simply asked verbatim to each woman. A flexible, conversational approach to discussing alcohol with pregnant women was considered superior to formal tools for identifying who might benefit from intervention and needs to be formally tested.”

Alcohol use in pregnancy can cause harm to the developing foetus, including growth restrictions, low birth weight, pre-term birth, and foetal alcohol spectrum disorders. There is little evidence of harm from very low levels of drinking but increasing risks as greater amounts are drunk more often.

SBIs are deployed in many care scenarios and, since 2003, clinical guidelines in Scotland have highlighted the importance of their use in antenatal care. In 2008, this was formalised as a national programme by setting a target for SBI delivery, with funding, training and materials rolled out across the country.

The programme was unprecedented in the UK – comparing with only a few initiatives internationally – and the design could provide a useful model in other jurisdictions.

The research team looked at how local health boards adapted, implemented and experienced the national SBI programme in antenatal care. It involved in-depth interviews with local implementation leaders to explore their experiences of implementing SBI in antenatal care.

Dr Fitzgerald said: “This is the first study to explore in detail the experiences of SBI implementation leaders of a large-scale primary prevention programme to prevent harm caused by alcohol exposure during pregnancy.

“It adds to understanding of the detailed practical and ethical dilemmas involved in establishing alcohol SBI in the antenatal setting, and is likely to be relevant to other countries.”

Dr Fitzgerald worked on the research – funded by Islington Primary Care Trust – with Lisa Schölin, of the School of Health in Social Sciences at the University of Edinburgh.

The new paper follows another from the same study, which focused on implementation in a range of settings.