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Table 3 Case studies from local areas

From: The conversation matters: a qualitative study exploring the implementation of alcohol screening and brief interventions in antenatal care in Scotland

Title Health Board Case study text
Case study 1: a conversational approach to screening Area D We designed a new screening tool because we felt that some of the tools for the antenatal session weren’t [in the kind of] language [used locally], midwives fed back that they weren’t comfortable with that.
Initially we looked at how we approached the alcohol questions. We found that women tell us that they don’t drink, they will always say they don’t drink, but we know that is not true. So we had to look at a way that it was more of a conversation than about asking women about normal drinking behaviour. We asked the midwives not to ask about units, [but instead] ask when they drink, how often, what they drink, how much … so asking a young girl what her normal pattern was of drinking, she said ‘at weekends’, I asked when that started, what she drank in the house before going out, when she goes out. It’s about knowing about normal patterns of drinking, it was asking specific questions rather than asking how much you would drink. At the time I found out that she was drinking over 100 units at the weekend but initially she said she was only drinking socially at the weekend … [emphasis added]
I think what I tended to find was that women were very defensive. They say I’m not going to drink and I’m going to stop now and it’s about reassuring them that that’s great. But also asking if it’s okay if we discuss that a bit more. Saying that we know that sometimes there are special occasions and they might say ‘I plan to have x, y, z’ or ‘I drank in my last pregnancy’ and the child is OK, then that’s more of an opening. But I would say those women are the ones that are less likely to want to have the conversation. I would ask them then about the effects of drinking to find out their knowledge then ask their permission ‘can we move on?’ and discuss other parts. Talk about their normal behaviour and ask ‘how easy is it going to be to make a change from that? How are you going to manage? What will you do to make that change?’ …
I think the big thing for us is the local culture and the local language that we use. I was trying to get away from the midwives using the initial screening tool as a parrot fashion and questions. I felt that the problem was that people don’t want to talk about it, taboo around asking questions about alcohol. We had an FAS event day locally and one speaker put up some research saying that women are drinking 2 units and so they don’t drink what we think they are, using the initial screening tool we were finding they were drinking 2 units or 1 unit less than once a month. But from what we see locally and especially the post I do, people tell me that they know somebody that drank in pregnancy. So we knew that those figures weren’t right. So [we thought about] what do we do to get the correct information?...
It’s also about reassuring them that they’re not being judged or there’s going to be some form of social work input. It’s about putting them at ease and having a different kind of conversation that was beneficial for us.
Case study 2: addressing changes in reporting over time Area G Screening focused on current, previous and pre-pregnancy drinking.
“Obviously the generic training we got was using the FAST [Fast Alcohol Screening Test] screening tool and it was quite clear from the word go that it wasn’t appropriate when we were going down the route of abstinence in pregnancy. That was a big issue for us initially, was the abstinence message, when there was the mixed message still going on about whether it was safe enough to use the 1–2 units once or twice a week or should we go the abstinence. However we got a lot of support locally, through the ADP and through our consultants and obstetricians as well, we were very supported in the abstinence message in [our health board]. So we decided to go with the direct questions that were already existing in the SWHMR notes, of how many units of alcohol are you drinking in the pre-pregnancy and how many units of alcohol you were drinking currently, but elaborating by asking about their pattern of drinking and establishing how many units they were drinking on their heaviest drinking day to capture the binge culture.”
Over a 9 month period, disclosures of pre-pregnancy drinking fell by over 20%.
“One of the key things that we’ve found in [this health board] bearing in mind that we’ve been screening [for almost 5 years]. Over the last 6–9 months, we were noticing when our pre-pregnancy drinking data was coming in that we were actually seeing a great increase in the number of people who were actually saying that they weren’t drinking any alcohol at all outwith pregnancy, even in their pre-pregnant drinking, it was around about 50–52% throughout all localities that women were now saying that they weren’t drinking any alcohol at all...We’ve only seen within the last 6–9 months that we are finding that 50% on average are saying they don’t drink any alcohol, prior to that, when we introduced the training and the screening … you would probably be sitting at over 75% who were describing their pattern of pre-pregnancy drinking. They were quite happy to describe their pre-pregnant drinking...”
This fall was not thought to reflect an actual fall in drinking.
We know within [this area] that we do have a problem with problematic binge drinking … we know that it’s an ongoing social factor here, so actually to look at the stats coming through of young women of childbearing age saying that they actually didn’t drink at all was questionable. So we approached the community midwives and got a feeling of their perception. We were a bit worried that it was the midwives who were losing the agenda, now that they were taking on other stuff, the GIRFEC agenda and other things going on, had this priority dropped?”
Women were thought to be ‘coming prepared’ to say they didn’t drink.
So we approached midwives, and obviously working within this field for years, I know midwives who are really good at specific agendas and really good at their screening, and even midwives like that were actually coming forward to myself and saying “its actually surprising ourselves, we feel the message is out there now [the screening] has actually been embedded for several years that women actually come prepared to say that they don’t drink any more.”
A greater focus on parenting and home circumstances may have contributed to the change.
“There was no kind of follow on about why they weren’t admitting it. I think there has been such a big shift with the GIRFEC agenda [a national early years child wellbeing initiative] and the total booking appointment and how many questions – how in-depth midwifes now go in their whole circumstances, whereas before we did the key screening on things, like domestic abuse, we now look really into their whole lifestyle, where they’re living, what benefits they’re getting, what their partners do, if there has been any criminal past – we actually go very, very in-depth on their parenting capacity and any concerns that might rise from that now, so I don’t know whether with us going into this agenda, that the actual fear of actually admitting that they were drinking regular and there had maybe been instances linked to that, that they had maybe been a bit afraid to disclose that. I am not really sure where the reasons come behind that but certainly that’s what the feedback from a lot of the community midwives was, was that women were coming pre-prepared and weren’t openly discussing what they were previously drinking.”
What was done in response to the fall in disclosure?
What we’ve actually done in relation to the early years collaborative/PDSA [Plan-Do-Study-Act] cycle that’s going on nationally we decided to do a bit of work within that to get a clear picture what percentages of women were advising that they don’t drink alcohol at all [pre-pregnancy] and also doing a wee bit of training for the midwifes in the community again.
So we looked at numbers for three locality areas, so on how many women were advising that they don’t drink any alcohol at all, and it was true the numbers that came in were 49/52/50% for women drinking no alcohol pre-pregnancy. So it was reflective of the figures we were finding in [part of the health board] and what the community midwives were saying to us as well.”
Focusing on more prompts led to greater disclosure back to original levels.
So next step was to focus on one community locality, and arranged to go out to speak to community midwives to have a conversation on what were their views on these stats over that last months. And they all replicated what has already been said that they felt women were already prepared and that they’ve been surprised about how many women … they were quite adamant that it wasn’t the competing agenda that was putting the priority down on their workload. So I then did a refresher course on what our policy is on the screening and when a brief intervention should be delivered and questioning their pattern of drinking when they’re pre-pregnant as well. And a lot of the midwives were again replying that women are telling us that they are not drinking.
So I encouraged them to take the probing a wee bit further and say, ‘you’re obviously saying that you’ve never drank pre-pregnancy but have you ever drank before?’ and ‘what was your pattern of drinking then?’ and ‘when did you last drink?’. So that we’re kind of taking it that next step. So the results from that was that our screening on the pre pregnant jumped back up to 74% in that area. Now in the stage where I’m linking in with the team leaders in the other localities and they will feed this info back to their community midwives highlighting this need for further probing.”