Midwives and service users' perspectives on implementing a dialogue about alcohol use in antenatal care: A qualitative study.

AIM: There are barriers to midwives engaging in conversations about alcohol with pregnant women. Our aim was to capture the views of midwives and service users to co-create strategies to address these barriers. DESIGN: Qualitative description. METHODS: Structured Zoom-based focus group interviews of midwives and service users where we presented known barriers and sought solutions to midwives discussing alcohol use in antenatal settings. Data collection took place between July and August 2021. RESULTS: Fourteen midwives and six service users attended five focus groups. Barriers considered were as follows: (i) lack of awareness of guidelines, (ii) poor skills in difficult conversations, (iii) lack of confidence, (iv) lack of belief in existing evidence, (v) women would not listen to their advice, and (vi) alcohol conversations were not considered part of their role. Five strategies to address barriers to midwives discussing alcohol with pregnant women were identified. These were as follows: Training that included mothers of children with Foetal Alcohol Spectrum Disorder, champion midwives, a service user questionnaire about alcohol for completion before the consultation, questions about alcohol added to the maternity data capture template and a structured appraisal to provide a means of audit and feedback on their alcohol dialogue with women. CONCLUSIONS: Co-creation involving providers and users of maternity services yielded theoretically underpinned pragmatic strategies to support midwives to ask advise assist about alcohol during antenatal care. Future research will test if the strategies can be delivered in antenatal care settings, and if they are acceptable to service providers and service users. IMPACT: If these strategies are effective in addressing barriers to midwives discussing alcohol with pregnant women, this could support women to abstain from alcohol during pregnancy, thus reducing alcohol-related maternal and infant harm. PATIENT AND PUBLIC CONTRIBUTION: Service users were involved in the design and execution of the study, considering data, supporting intervention design and delivery and dissemination.

Fetal alcohol spectrum disorders: an overview of current evidence and activities in the UK.

Estimates for the UK suggest that alcohol consumption during pregnancy and prevalence of fetal alcohol spectrum disorder (FASD)-the most common neurodevelopmental condition-are high. Considering the significant health and social impacts of FASD, there is a public health imperative to prioritise prevention, interventions and support. In this article, we outline the current state of play regarding FASD knowledge and research in the UK, which is characterised by a lack of evidence, a lack of dedicated funding and services, and consequently little policy formulation and strategic direction. We highlight progress made to date, as well as current knowledge and service gaps to propose a way forward for UK research.

An antenatal alcohol service evaluation of the north-east of England and north Cumbria.

BACKGROUND: NHS England's 'Better Births' strategy aims to improve maternal and infant health outcomes. A strategic priority identified in the north-east local maternity system is to reduce alcohol consumption in pregnancy due to the documented diverse risks of harm to mother and baby, including foetal alcohol spectrum disorder. AIMS: To evaluate current alcohol prevention, screening and treatment service provision in maternity care across the region, and inform future recommendations. METHODS: A service evaluation survey was developed to systematically consult strategic stakeholders across all nine maternity trusts in the region over a 2-month period in 2018. Content analysis was employed to identify fundamental themes and inform recommendations for practice. RESULTS: High variation was reported throughout regional clinical practices, service provision and staff training. For example, a number of alcohol screening tools were identified, each with diverse thresholds for referral; reported data collection and documentation practices were multifarious, incomparable and unquantifiable; audit was rare and guidelines were primarily influenced by local commissioning agreements. DISCUSSION: Standardized patient pathways involving alcohol screening and management practices are required, and sharing best practices will facilitate referrals and support regardless of location. The implementation of these recommendations requires appropriate leadership, commissioning and training strategies.

Assessing the prevalence of alcohol consumption in early pregnancy using blood biomarker analysis: a consistent pattern across north-east England?

BACKGROUND: We previously investigated the prevalence of alcohol consumption in early pregnancy in Northumbria Healthcare NHS Foundation Trust, a locality of north-east England. The prevalence was 1.4% based on blood sample biomarker analysis using carbohydrate deficient transferrin (CDT) and 3.5% for gamma-glutamyltransferase (GGT). AIMS: To supplement this research by investigating the prevalence of alcohol use using identical methods in a different locality of the same region. METHODS: Six-hundred random blood samples taken at the antenatal booking appointment were anonymously analysed for the presence of CDT, a validated marker of chronic alcohol exposure (normalizing 2-3 weeks from abstinence) and GGT, a liver enzyme elevated for up to 8 weeks after alcohol exposure. RESULTS: The North Tees and Hartlepool NHS Foundation Trust data revealed a CDT prevalence rate of 1.7% (95% CI: 0.7-2.9) and GGT prevalence rate of 4.2% (95% CI: 2.6-5.9). However, these measures are not sensitive to low levels of alcohol; and no overlapping cases were identified or a significant correlation demonstrated between CDT or GGT. DISCUSSION: These data support our earlier work. Prevalence rates according to CDT and GGT analysis were similar in both areas, suggesting similar patterns of sustained alcohol use in pregnancy across the region.

A Survey of Health Care Professionals' Knowledge and Experience of Foetal Alcohol Spectrum Disorder and Alcohol Use in Pregnancy.

BACKGROUND: Foetal alcohol spectrum disorders (FASDs) are one of the most common preventable forms of developmental disability and congenital abnormalities globally, particularly in countries where alcohol is considered socially acceptable. Screening for alcohol use early in pregnancy can facilitate the detection of alcohol-exposed pregnancies and identify women who require further assessment. However, only a small percentage of children with FASD are identified in the United Kingdom. This may be partly attributed to a lack of awareness of the condition by National Health Service (NHS) health professionals. METHODS: We developed an online survey to determine health care professionals' (midwives, health visitors, obstetricians, paediatricians, and general practitioners) perceived knowledge, attitudes, and clinical practices relating to alcohol in pregnancy and FASD. RESULTS: There were a total of 250 responses to the surveys (78 midwives, 60 health visitors, 55 obstetricians, 31 paediatricians, and 26 general practitioners). About 58.1% of paediatricians had diagnosed a patient with foetal alcohol syndrome (FAS) or FASD and 36.7% worried about stigmatisation with diagnosis. Paediatricians reported the highest levels of FASD training (54.8%), with much lower levels in midwives (21.3%). This was reflected in perceived knowledge levels; overall, only 19.8% of respondents knew the estimated UK prevalence of FASD for example. CONCLUSIONS: We identified a need for training in alcohol screening in pregnancy and FASD to improve awareness and recognition by UK professionals. This could improve patient care from the antenatal period and throughout childhood.

Assessing prevalence of alcohol consumption in early pregnancy: Self-report compared to blood biomarker analysis.

Providing appropriate antenatal and postnatal care for women who drink alcohol in pregnancy is only possible if those at risk can be identified. We aimed to compare the prevalence of alcohol consumption in the first trimester of pregnancy using self-report and blood biomarker analysis. Six-hundred routine blood samples from 2014, taken at the antenatal booking appointment, in the first trimester of pregnancy, were anonymously analysed for the presence of Carbohydrate Deficient Transferrin (CDT), a validated marker of chronic alcohol exposure (normalising 2-3 weeks from abstinence) and Gamma-glutamyltransferase (GGT), a liver enzyme elevated for up to 8 weeks after alcohol exposure. In a separate sample of women, from 2015, data taken during the antenatal visit, documenting women's self-reported alcohol consumption, were collected. The percentage of women who reported alcohol intake in the first trimester was 0.8%. This compared to 74.1% of women who reported consuming alcohol before pregnancy. CDT analysis revealed a prevalence rate of 1.4% and GGT a prevalence rate of 3.5% in the first trimester of pregnancy. Although those with elevated CDT generally had high levels of GGT, only one person was positive for CDT and GGT. Results from CDT analysis and self-report may underestimate prevalence for different reasons. GGT appeared to lack specificity, but it may have value in supporting findings from CDT analysis. Further studies using additional blood biomarkers, or a combination of blood biomarkers and self-report, may be beneficial in accurately detecting alcohol drinking history in pregnancy.

How strong is the evidence for using blood biomarkers alone to screen for alcohol consumption during pregnancy? A systematic review.

Accurate and early identification of women at risk from alcohol consumption during pregnancy allows education and support programmes to be targeted at those most in need. We aimed to conduct a systematic review to compare the efficacy of blood analysis and maternal self-report in detecting at risk women during pregnancy. This review investigated diagnostic accuracy. We searched four databases (Medline, Embase, Psychinfo and CINAHL) for relevant articles and conducted hand searches of recent issues of key journals in the field. No restriction was placed on inclusion in terms of publication date or language. Studies were deemed eligible if they were original research and included a direct comparison of the results of blood biomarker analysis and self-reported alcohol use for the detection of alcohol consumption in pregnant women. Quality appraisal of included studies was conducted using the QUADAS II tool. Eight studies met the inclusion criteria. Gamma-glutamyltransferase (GGT) was investigated in five studies, mean corpuscular volume (MCV) and phosphatidylethanol (PEth) in three studies and carbohydrate deficient transferrin (CDT), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and whole blood associated acetaldehyde assay (WBAA) were each investigated in two studies. Although all of the studies were rated of good methodological quality, none of the biomarkers had both high sensitivity and specificity when compared to self-report. There was some evidence that a combination of biomarkers, or combining biomarkers with self-report, increases accuracy. In summary, the blood biomarkers examined were of limited use in screening for low and moderate alcohol consumption in pregnancy when compared to self-report. However, certain biomarkers, such and CDT and PEth may complement self-report and help improve the accuracy of diagnosis.