1. Attitudes to smoking and drinking in pregnancy and their effect on the delivery of health interventions Faculty of Public Health Scotland Dr Debbie Wason Dr Esther Curnock NHS Ayrshire & Arran

2. ‘I would have an odd drink but I’m not a drinker. I told her I didn’t drink and she didn’t really have anything to say’

3. Outline Background Findings –Behaviour –Context –Interventions Conclusions

4. Background Negative health impact –Tobacco –Alcohol Behaviours in pregnancy Scottish Government Policy

5. Specialist Midwife Posts Support women to quit smoking in pregnancy Offer support to women with previous alcohol issues or alcohol use in pregnancy Train & support midwives in offering Alcohol Brief Interventions and tobacco screening

6. Findings

7. Smoking Cessation Referrals = 674 Contacts = 319 Quit date set = 107 4 week f/u = 63 4 week quits = 57 12 week f/u= 33 12 week quits = 26

8. Drinking prior to Pregnancy 814 questionnaires NHS A&A Scotland (women 16-44 yrs) Harmful drinkers (>35 u/wk)3%4% Hazardous drinkers (14-35 u/wk)10%19% Moderate drinkers63%67% Non-drinkers24%10%

9. Who keeps drinking? 46 women still drinking at booking 5% of moderate drinkers 10% of hazardous drinkers 10% of harmful drinkers Or so they say………

10. Last drink by time to EDD

11. Context What do people mean by ‘drinking’? ‘They’ll think only a night binge drinking is the bad thing’ (Midwife) ‘Now they tell me you shouldn’t drink at all which is fair enough. If I’m out for dinner I’ll just have a wee glass of wine’ (pregnant woman)

12. Context Midwives can be uncomfortable about discussing drinking alcohol in pregnancy ‘And you have to watch what you’re saying because if that’s the first time you’re meeting these women… You can’t be too critical’(midwife) ‘A lot of girls will admit to using drugs but most of them don’t admit to taking alcohol. Some of them think it’s worse’ (midwife)

13. Context Some midwives are ambivalent around the issue of alcohol. ‘One minute the news is saying it’s okay to have one glass and then we’re saying we’re not really advising them to take any alcohol at all.’ (Midwife)

14. ‘Some are trying to reduce their methadone and their smoking as well. Which is the one that they really concentrate on? They’re not going to cut out both necessarily.’ (midwife) ‘I think it’s also raised the issue with midwives themselves because it’s common practice to smoke, the drinking is a bit more hidden but it’s so normal that even as midwives there are many bigger issues.’ (midwife)

15. Context Differences between alcohol and smoking –Admitting the activity ‘Do you feel that women are more relaxed about admitting to smoking than drinking? Yes. Why do you think that is? I think it’s (smoking) is more acceptable.’ (midwife) –Monitoring and detection – the CO Monitor –Perception of addictive nature

16. Context Unproven harms of alcohol use at low levels ‘But on the alcohol one, it feels a bit like we don’t know. Nobody’s done research on one unit, once a month, in the last six months and what, if any, effect that has.’ (pregnant woman)

17. Interventions -Timely messages Pre-pregnancy ‘They should maybe run pre-conceptional clinics because what’s happening is people binge drink, then they find they are pregnant and it’s already into the 12 weeks.... and some past 12 weeks. Those are the crucial weeks of formation of that child and sometimes we are shutting the stable door after the horse’s bolted.’ (midwife)

18. Interventions - Pre-booking Alcohol is discussed at pre-booking but many other messages are given then also. - Later in Pregnancy Women could not recall the issue of alcohol being addressed in later pregnancy.

21. Interventions Advice needs to be for life not just for pregnancy ‘Last year I stopped myself (smoking) and I fell pregnant. I had a miscarriage and then I started again. I was gonna start smoking because I don’t need to stop now. So when this time came around obviously I thought I should stop smoking again. It just wasn’t as easy.’ (pregnant woman)

22. Conclusion Pregnancy can be a great time to address behaviour change. Smoking is more akin to drug misuse than alcohol consumption. For midwives, discussion around alcohol use seems the most difficult. Discussions re. alcohol need to be held at different stages in pregnancy

23. Acknowledgements Dr Maggie Watts and the Steering Group for Specialist Midwives Angela Cunningham, Head of Midwifery, NHS Ayrshire and Arran The Specialist and Community Midwives The pregnant women

24. Any questions?? Contact details: –esthercurnock@nhs.netesthercurnock@nhs.net –Deborah.wason@aapct.scot.nhs.ukDeborah.wason@aapct.scot.nhs.uk