Elsevier

Midwifery

Volume 28, Issue 3, June 2012, Pages 314-320
Midwifery

Towards improved alcohol prevention in Swedish antenatal care?

https://doi.org/10.1016/j.midw.2011.04.008Get rights and content

Abstract

Objective

to evaluate an education effort and revised alcohol-preventive routine in Swedish antenatal care; to generate more knowledge for further development of alcohol issues in antenatal care.

Design

two national cross-sectional surveys of Swedish midwives were conducted. Baseline data were collected in 2006 and follow-up data in 2009.

Setting

antenatal care centres in Sweden.

Participants

974 midwives in 2006 and 1108 midwives in 2009.

Measurement

amount and content of continuing professional education, work with alcohol-related issues, identification of women with risky consumption of alcohol, and action after identifying women with risky consumption.

Findings

the amount of continuing professional education undertaken by midwives on handling risky drinking increased significantly between 2006 and 2009. The routine to detect risky drinking changed between the baseline and follow-up data collection, as nearly all midwives reported the use of an alcohol screening questionnaire in 2009. The most confident midwives in 2009 had taken part in more days of education, more often stated it was their own initiative to participate, and had more often taken part in education regarding MI, provision of advice and information on the health risks associated with alcohol and, screening.

Key conclusions

our results indicate that a broad, national education effort can be successful in enhancing knowledge and changing antenatal care practice. However, generalisation to other countries or cultures may be limited because the usage of new routines is affected by many organisational and contextual factors.

Introduction

Alcohol use during pregnancy is one of the leading preventable causes of mental retardation and developmental disabilities (Abel and Sokol, 1987). It has also been linked to a number of health consequences including intrauterine growth retardation, low birth weight, and attention problems (Mills et al., 1984, Sampson et al., 1994, Carmichael Olson et al., 1997, Sood et al., 2001). As maternal alcohol intake increases, there is a corresponding increase in the adverse effects observable in the fetus (Stratton et al., 1996). There is no universally safe level of prenatal alcohol use. Even fairly small amounts of alcohol have been found to cause adverse neurobehavioral effects on children (Streissguth et al., 1994, Sayal et al., 2007) Thus, early identification of alcohol use and interventions to modify drinking habits are highly desirable.

Health authorities in many countries have published guidelines that recommend abstinence during pregnancy. For example, in the USA abstaining from alcohol is recommended for women who are or may become pregnant and the recommendations state that no safe level of alcohol consumption has been established (U.S Department of Agriculture and U.S Department of Health and Human Services, 2010). In the UK the recommendations for antenatal care is to advise pregnant women and women planning a pregnancy to avoid drinking alcohol in the first three months of pregnancy and if women choose to drink alcohol during the pregnancy she should be advised not to drink more than two units (16 g of pure alcohol) once or twice a week (NICE, 2008). Midwives in Swedish antenatal care are recommended to communicate to pregnant women that there is no safe level of alcohol consumption during pregnancy and that total abstinence during pregnancy is the safest option (Swedish National Institute of Public Health, 2009a).

Sweden has a comprehensive system of public antenatal care units, which has been successful in reaching nearly all pregnant women since the 1970s (Åberg and Lindmark, 1992). Swedish health care, including antenatal care, is publicly funded. Residents are insured by the state and health-care services are funded through a taxation scheme by county councils. The aim of the antenatal care system is to identify health risks for mother and/or child and prevent morbidity. This is achieved through interventions for prevention of psychosocial and physical health risks, including alcohol consumption, or referrals to specialized care if needed (Göransson, 2004).

Until recently, standard Swedish antenatal care has involved an initial meeting between a midwife and the pregnant woman some time during weeks 10–12 of the pregnancy. This consultation addressed the woman's health status and included a question about the frequency of current drinking (the reply was marked in the woman's medical record). She was recommended to abstain from drinking during the pregnancy. Further meetings between the midwife and the pregnant woman were held in week 20 (only for those expecting their first child), 25, 29, 30–32, 37, and 39. The meeting in weeks 30–32 included a question on alcohol habits during the pregnancy. The woman usually met the same midwife throughout the pregnancy. Women with a previous disease or a complicated pregnancy also met with an obstetrician.

A slightly revised antenatal care routine was initiated in 2005 and has gradually been implemented throughout Sweden, with full implementation expected to be reached during 2010. The main difference compared with the previous routine is that the initial health status meeting is now two shorter separate consultations and the Alcohol Use Disorders Identification Test (AUDIT) questionnaire is completed by all women. In the new procedure, a woman who approaches antenatal care after pregnancy recognition receives an appointment with a midwife within a week of the initial contact. Health issues are discussed at this meeting, and alcohol use is an important element. At the meeting, the woman fills in the AUDIT questionnaire concerning her alcohol use the year preceding the pregnancy. The AUDIT results are then reviewed together with the midwife and provide the basis for a discussion. A timeline follow back is conducted if a woman is concerned about having drunk alcohol in the early stage of the pregnancy. A second consultation follows up on the initial meeting. The remaining meetings are the same as in the previous routine.

The revised alcohol-preventive model was instigated as part of the Risk Drinking Project, which was launched in 2005 by the Swedish government and ceased at the end of 2010. The project is part of a concerted strategy to facilitate improved alcohol prevention in routine health care. The overall aim of the project was to improve early detection of non-treatment-seeking, non-dependent risky drinkers, and address alcohol with greater frequency than before. To achieve this goal, health professionals received continuing professional education on various alcohol-related matters. Antenatal care midwives throughout Sweden received training in motivational interviewing (MI) counselling techniques, general information on alcohol-related health issues, and the use of the AUDIT questionnaire. Impetus for revision of the routines in Sweden came from domestic research that has documented high prevalence of drinking during pregnancy and found that AUDIT scores for the year prior to the pregnancy predict alcohol use during pregnancy (Göransson, 2003).

This study investigated on a national basis the amount and content of continuing professional education on alcohol-related issues among Swedish midwives, alcohol-preventive practices, and knowledge concerning identification of drinking by pregnant women and the health risks associated with alcohol use. Some of the results from a baseline questionnaire in 2006 are compared with those of a follow-up questionnaire in 2009 (please see Holmqvist and Nilsen (2010) for results from the baseline study). The study is important for evaluating the ambitious revised alcohol-preventive routine in antenatal care and to generate more knowledge for further development of work with alcohol issues.

Section snippets

Data collection

Baseline data were collected by means of an anonymous questionnaire. The questionnaire was sent in March and April 2006 to all 2106 midwives employed in antenatal care within primary care in Sweden. A written reminder was sent to all participants two weeks after the initial mailing and a second reminder was sent two weeks after the first one.

Follow-up data were collected using the same procedure. Anonymous questionnaires were sent to all 1796 midwives in Sweden in May–June 2009. The

Response rates and respondent characteristics

The baseline questionnaire was returned by 1159 midwives (55% response rate). A total of 185 were excluded because they did not reach the target population of this study. Most of the midwives who were excluded worked in the adolescent health services. The total number of midwives included in the analysis was 974, representing 46% of the total number of distributed questionnaires. The follow-up questionnaire was returned by 1221 midwives (68% response rate). A total of 113 midwives did not work

Discussion

This investigation among Swedish midwives on their education on alcohol-related issues, alcohol-preventive practice, knowledge about alcohol-related health issues, and identification of risky drinkers showed considerable differences between the 2006 baseline and the 2009 follow-up questionnaire. There are also notable differences between the most confident midwives and all other midwives in 2009. The midwives took part in a substantial number of continuing professional education events in the

Conclusions and implications

A revised antenatal care routine for alcohol prevention has been implemented in Sweden. This has coincided with education provided for midwives as part of a national project, the Risk Drinking Project. There has been a significant increase among the midwives in the amount of education on handling risky drinkers between 2006 and 2009. The midwives perceived knowledge about alcohol and pregnancy, and on detecting women with risky drinking before the pregnancy, has increased considerably. The most

Conflict of interest

None to declare.

Acknowledgements

The authors would like to thank the Swedish National Institute of Public health for funding of this study, and the midwives participating in the study.

References (28)

  • T. Greenhalgh et al.

    Diffusion of Innovations in Health Service Organisations: A Systematic Literature Review

    (2005)
  • R.M. Groves et al.

    The impact of nonresponse rates on nonresponse bias: a meta-analysis

    Public Opinion Quarterly

    (2008)
  • J. Malcolm et al.

    The interrelationships between informal and formal learning

    Journal of Workplace Learning

    (2003)
  • V. Marsick et al.

    Informal and Incidental Learning in the Workplace

    (1990)
  • Cited by (9)

    • Consumption of alcohol during pregnancy—A multinational European study

      2017, Women and Birth
      Citation Excerpt :

      Two Danish studies have shown that giving alcohol advice to pregnant women has increased among midwives and general practitioners during the 21st century.27,28 To further increase the advice in maternal care, a Swedish national intervention containing education regarding motivational interviews and the risks with alcohol during pregnancy has been tested with positive results.29 As another way, an evaluation of the Scottish antenatal care routines has suggested person-centered communication interventions for personnel in antenatal care.30

    • Norwegian midwives' use of screening for and brief interventions on alcohol use in pregnancy

      2015, Sexual and Reproductive Healthcare
      Citation Excerpt :

      Perceived competence for BI was, however, higher for those who had received MI traning more than once, regardless of whether it was in a BI context or not. In Sweden, it was found that three or more days of training was necessary to make a difference in BI utilization [29,31]. One can learn some MI through a two-day workshop [32], but it is more effective to have (1) a little more time to learn MI in a stepwise fashion with the focus on spirit before techniques, (2) systematic feedback on own conversations, and (3) supervision [33].

    • A qualitative investigation of alcohol use advice during pregnancy: Experiences of Dutch midwives, pregnant women and their partners

      2013, Midwifery
      Citation Excerpt :

      A Swedish national education project showed that the use of the Alcohol Use Disorders Identification Test (AUDIT) in the regular consultations of antenatal care improved the screening of antenatal alcohol use (Skagerström et al., 2012). Moreover, the knowledge of midwives with regard to alcohol in pregnancy was improved by the project's facilitation of training in general information on alcohol-related health issues (Skagerström et al., 2012). The role of the Swedish midwives in educating pregnant women is comparable to the Dutch situation (Kateman and Herschderfer, 2005).

    • Health advice on alcohol consumption in pregnant women in Seville (Spain)

      2020, Gaceta Sanitaria
      Citation Excerpt :

      Other professional sectors, such as social services personnel, the staff of school guidance departments and of early childhood intervention centers, should also receive information about FASD. The impact of FASD training on professional practice has already been shown in countries such as the United States and Sweden.24,37 The WHO European Action Plan to Reduce the Harmful Use of Alcohol (2012-2020) establishes, amongst other measures, the relevance of interventions carried out by the healthcare provider with pregnant women.

    View all citing articles on Scopus
    View full text