Midwifery led alcohol education

In the UK approximately half of women drink alcohol during pregnancy, 8% drink above recommended safe limits (1 or 2 units once or twice a week), and a quarter receive no health advice on safe levels of consumption.1,2 It is widely accepted that high alcohol consumption or regular binge drinking during pregnancy increases the risk of miscarriage, premature birth and a low birth weight.3,4 It can also cause foetal alcohol spectrum disorder (FASD), a range of physical and mental disabilities that persist throughout life.5  Although evidence reviews have concluded that there is no consistent evidence of harm caused by low to moderate alcohol consumption during pregnancy, new evidence continues to emerge of the potential risks (e.g. for low birth weight and foetal death).4,6,7,8

As part of the ‘Responsibility Deal Alcohol Network (RDAN)’, the Government is working with the alcohol industry to ‘foster a culture of responsible drinking’ and to ensure that alcohol products will have ‘a warning about drinking when pregnant’.9 In addition the UK Alcohol Strategy encourages hospitals to identify and support pregnant women who drink during pregnancy.10 In support of this policy Diageo (an international drinks retailer) will provide funding for the National Organisation for Foetal Alcohol Syndrome (NOFAS-UK) to provide face-to-face, online and distance learning to 10,000 midwives (one-third of the England and Wales workforce).11  Midwifes will be trained to:12

  • Provide information and advice about the dangers of alcohol during pregnancy,
  • Encourage complete abstinence from alcohol during pregnancy. NOFAS believe that any amount of alcohol carries a risk of FASD.
  • Screen women for patterns of alcohol use,
  • Deliver brief interventions or referral to appropriate specialists for all women who drink alcohol.

Evidence of the benefits

The aim of the midwife-led scheme is to encourage women not to drink during pregnancy and to reduce the incidence of alcohol related birth defects.12

Various evidence reviews have concluded that brief advice and interventions are effective in reducing alcohol consumption and alcohol-related harm in adults.13 These interventions appear effective when delivered in primary care (GP surgeries), rather than hospital settings.

A single evidence review has looked at interventions for reducing alcohol consumption during pregnancy (for women attending hospital antenatal care).14 This found sparse and weak evidence that psychological and educational interventions led to reduced alcohol consumption or increased abstinence. The authors concluded that there was no information on whether interventions led to positive health effects for mothers and babies. Further work has reviewed studies looking at midwife home visits after birth finding no evidence of a reduction in alcohol use or proven health benefits.15

Secondary benefits of midwife-led interventions have also been explored. These demonstrate an increased emphasis on the safeguarding of children that arise from midwife-led alcohol interventions.16 In addition a single study has demonstrated that screening women during antenatal care improves disclosure of problem drinking.17

There has been more research looking at midwife-led support for women with substance misuse (specifically heroine/methadone). Here, single studies have shown interventions can result in:

  • A more positive attitude towards women with drug or alcohol problems18,19
  • A greater likelihood of referral to other specialist services and continuity of care18,19
  • Earlier identification of women with alcohol problems and reduced hospital admissions20

Evidence of the risks

The risk of an increased focus on alcohol is that it may deter women from attending antenatal care, lead to fear of losing custody of their children and cause them to feel ‘policed’ (particularly during home visits).21

A further danger is that heavy investment, specifically in midwife training, may deflect or delay investment in broader and more evidence-based interventions. For example, NICE have recommended that women who misuse alcohol should receive care packages coordinated across agencies, and that training about complex needs should cross professional boundaries.16

Finally, Diageo’s investment appears to support their efforts towards corporate social responsibility, but may in fact deflect attention from their opposition to more evidence based pledges within alcohol policy, e.g. minimum alcohol pricing.22

Implications for health and well-being

There is limited evidence that midwife-led advice and brief interventions reduce alcohol consumption during pregnancy, or reduce alcohol related birth defects. However, research into the needs of pregnant women who misuse alcohol or drugs support the use of specialist midwifes based within multiagency teams.  The NOFAS-UK scheme supports abstinence for all pregnant women regardless of alcohol consumption so its impact is difficult to predict. The UK Government should clarify how this scheme is to be evaluated and encourage further research into how midwife-led interventions can reduce alcohol related harm.16

Author

Duncan L Cooper, PhD, Specialty Registrar in Public Health, Born in Bradford Cohort Study, Bradford Institute for Health Research

References

  1. NHS Information Centre (2005). Infant Feeding Survey. Available at http://www.ic.nhs.uk/pubs/ifs2005 Accessed 7th November 2012.
  2. Science and Technology Committee. Eleventh Report: Alcohol Guidelines. 2011. Available at http://www.publications.parliament.uk/pa/cm201012/cmselect/cmsctech/1536/153602.htm Accessed 15th December 2012.
  3. Gray R, Henderson J. Report to the Department of Health: Review of the Fetal Effects of Prenatal Alcohol Exposure. University of Oxford: National Perinatal Epidemiology Unit 2006.
  4. Royal College of Obstetricians and Gynaecologists (2006). Alcohol Consumption and the Outcomes of Pregnancy (RCOG Statement No.5). London: RCOG. Available at http://www.rcog.org.uk/files/rcog-corp/uploaded-files/RCOGStatement5AlcoholPregnancy2006.pdf  Accessed 7th November 2012.
  5. Mattson SN, Crocker N, Nguyen TT. Fetal alcohol spectrum disorders: neuropsychological and behavioral features. Neuropsychol Rev 2011: 21(2):81-101.
  6. Henderson JR, Gray R, Brocklehurst P. Systematic review of effects of low–moderate prenatal alcohol exposure on pregnancy outcome. BJOG 2007;114:243–252.
  7. Meyer-Leu Y, Lemola S, Daeppen JP, et al. Association of Moderate Alcohol Use and Binge Drinking During Pregnancy with Neonatal Health. Alcoholism: Clinical and Experimental Research 2011;35(9):1669–1677.
  8. Andersen AMN, Andersen PK, Olsen J, et al. Moderate alcohol intake during pregnancy and risk of fetal death. Int. J. Epidemiol  first published online October 13, 2012 doi:10.1093/ije/dys155.
  9. Department of Health (2011). The Public Health Responsibility Deal. Available at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_125237.pdf Accessed 29 July 2011.
  10. HM Government (2012). The Government’s Alcohol Strategy. The Stationary Office: London. Cm 8336.
  11. Department of Health (2012). Diageo individual pledge supports midwives on alcohol and pregnancy. Available at http://responsibilitydeal.dh.gov.uk/2012/08/21/diageo-alcohol-and-pregancy/ Accessed 29 July 2011.
  12. NOFAS-UK. Alcohol and pregnancy: Information for Midwifes. The National Organisation for Foetal Alcohol Syndrome UK.
  13. National Institute for Health and Clinical Excellence (2010). Alcohol-use disorders: preventing the development of hazardous and harmful drinking (PH24). London: NICE.
  14. Stade BC, Bailey C, Dzendoletas D, Sgro M, Dowswell T, Bennett D. Psychological and/or educational interventions for reducing alcohol consumption in pregnant women and women planning pregnancy. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD004228. DOI: 10.1002/14651858.CD004228.pub2.
  15. Turnbull C,OsbornDA. Home visits during pregnancy and after birth for women with an alcohol or drug problem. Cochrane Database of Systematic Reviews 2012, Issue 1. Art. No.: CD004456. DOI: 10.1002/14651858.CD004456.pub3.
  16. National Institute for Health and Clinical Excellence (2010). Pregnancy and complex social factors. (CG110). London: NICE.
  17. Clark KA, Dawson S, Martin SL. The effect of implementing a more comprehensive screening for substance use among pregnant women in North Carolina. Matern Child Health
  18. Corse SJ, McHugh MK, Gordon SM. Enhancing provider effectiveness in treating pregnant women with addictions. J Subst Abuse Treat 1995; 12:(1)3-12.
  19. Economidoy E, Klimi A, Vivilaki VG. Caring for substance abuse pregnant women: The role of the midwife. Health Science Journal 2012; 6(1): 161-9.
  20. D’Souza SW, Miles J, Sugumar K et al. Methadone-exposed newborn infants: outcome after alterations to a service for mothers and infants. Child: Care 2007; 33:(2)206-12.)).
  21. Phillips D, Thomas K, Cox H. Factors that influence women’s disclosures of substance use during pregnancy: A qualitative study of ten midwives and ten pregnant women. J Drug Issues 2007; 37:(2)357-76.
  22. Health Committee – The Government’s Alcohol Strategy Written evidence from Diageo (GAS 34). Parliamentary copyright. 2012. Available from http://www.publications.parliament.uk/pa/cm201213/cmselect/cmhealth/132/132vw31.htm. 2012 Accessed 19th December, 2012.

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