Midwives need more support to deliver advice on alcohol consumption in pregnancy

A new study funded by the Institute of Alcohol Studies – ‘Alcohol guidelines for pregnant women: Barriers and enablers for midwives to deliver advice’ – highlights the inconsistency in official guidance that led to midwives giving different advice on alcohol consumption in pregnancy. Nine out of ten midwives reported alcohol abstinence was advised within the guidelines, however four out of ten midwives were not aware of the actual content of the 2016 alcohol guidelines on pregnancy.

The study included a survey and qualitative interviews with UK-based midwives. The study showed that 58% of respondents were aware of the CMO guidelines, almost all of whom (91%) advised abstaining from alcohol. 19% reported that a limit of 1-2 units once or twice per week was part of the guidelines, which was in line with the National Institute for Health and Care Excellence (NICE) guidance that was only updated to reflect the CMO guidelines in December 2018. Almost all midwives (99%) referred women who they believed may have an alcohol problem to an appropriate agency.

The study highlights that there is no standardized approach to screening for alcohol consumption during antenatal appointments. Many midwives were adopting a non-judgemental approach of encouraging disclosure through ‘open conversations.

Although nearly all midwives (97%) ‘always’ or ‘usually’ advised all women to abstain from alcohol during pregnancy at the booking appointment (the first appointment), the proportion of who did so at later appointments fell to 38%. The survey also found that two thirds (65%) of midwives ‘always’ or ‘usually’ reported discussing the effects of drinking on the woman and her baby at booking, but this fell by half for subsequent appointments (to 31%).

Most also reported having little formal alcohol training: 69% of midwives had received fewer than four hours of alcohol training pre-qualification and 19% had received none. After qualifying, 33% of midwives had not received any alcohol-related training, and only 25% were offered this within annual training updates.

Royal College of Midwives Professional Policy Advisor Clare Livingstone welcomed the report’s findings for highlighting these important aspects of antenatal care.

‘Midwives are responsible for communicating vital health messages to women during pregnancy and rely on official guidance to ensure their advice is evidence based and up to date. This study shows the consequences of the CMO and NICE being out of step, resulting in mixed messaging around alcohol consumption in pregnancy.’

‘A standardized approach to alcohol screening and advice would eliminate these discrepancies and support midwives in their role.

‘Effective communication of official guidance and appropriate training is essential in ensuring that health professionals are giving consistent advice to women on such an important issue as alcohol abstinence in pregnancy.’

Analysis of survey results showed three areas that midwives scored as barriers to advising abstinence at appointments other than booking: women disliking being advised; midwives not feeling confident; and not feeling the advice will have any impact. On the other hand, midwives' scores indicated several facilitators to advising abstinence: desire to give the advice; seeing it as part of their role; and feeling that it's expected of them.

Ultimately, the researchers concluded that midwives were supportive of advising complete abstinence, agreeing with the underpinning rationale of the ‘precautionary principle’. However, there is room for improvement on the communication of the CMO guidelines to midwives, and on the amount of alcohol training midwives receive.

Lead author Lisa Schölin said:

Our findings that 42% midwives were not aware of the CMO guidelines suggests that the government did not effectively communicate the introduction of these updated recommendations. The CMO guidelines were introduced almost three years before the NICE guidelines were updated in line with them, meaning that during that time both guidelines were live, and no coherent message was given from all sources midwives may refer to. We also found that approaches varied greatly across the UK and whilst adaptation and tailoring is important, more needs to be done to standardize approaches to assessment and recording of alcohol consumption and associated care pathways. That would allow us to better compare and understand the impact of services across the UK."