Barriers and Challenges

The goal of the ABI initiative was to embed the intervention into an already established antenatal care system. In common with any innovative programme, there are bound to be challenges that need to be identified and overcome to ensure implementation success. Particularly, in antenatal settings, it is widely known that challenges led to a delay in the implementation of the intervention as compared to the other two settings of primary care and A&E. The SG national lead for ABI delivery in Scotland explained:

...and a lot of Boards as SG2 indicated, it was later on, it was maybe into year 2 or some were a wee bit late, into year 3 of the target before they started looking at antenatal just purely because of the challenges we have talked about. They looked at the delivery in primary care and A&E first and then to antenatal third (SG1).

Further to this, I explored from policy implementers point of view, the challenges they had already identified from the initial implementation process or the barriers they

168

envisaged may influence successful embedding of screening and ABI delivery into routine antenatal care. The biggest challenge they indicated was the time allocated for midwives to deliver the intervention. Others include midwives and pregnant women’s attitudes to alcohol in pregnancy, and issues associated with the screening tools currently being used and cultural issues.

All participants identified time for midwives to screen and deliver ABI as the biggest challenge. Below are the abstracts of participants when asked:

I: Considering the limited evidence base of ABI in antenatal, what do you think are the main challenges for implementing this intervention in antenatal settings?

HS2: Well I think the main challenges are undoubtedly, time. Whereas we say screening and ABI shouldn’t be a very lengthy process, it still require some time to be allocated to it. So alcohol is competing with a range of other things for that valuable time.

HS1: There is also a bit more practical issues about time at the booking appointment. As I said there is a whole host of issues that midwives are going through with women, like smoking, like diet, like physical activity, like general health behaviour, about the changes women go through about being pregnant and with all the different other appointment they have got to keep. So alcohol is competing with a lot of different other issues. So the time to address appropriately and get good information is again limited.

Since screening and ABI were competing with other equally important issues at the booking appointment, time was connected with the notion of how midwives assign significance to the issue of drinking in pregnancy. At present, policy implementers felt midwives were slightly underestimating the implications of alcohol use in pregnancy.

Participants argued that alcohol should be given the priority it deserves by midwives, by according it with the same urgency given to other important issues that need to be discussed at the booking appointment.

169

I think a bigger issue is whether compared to the range of other things that have to be addressed, you know whether alcohol is of sufficient priority to merit the use of valuable time (HS2).

The issue of time is very crucial to the delivery of the intervention. Because if time is limited, it means midwives may not be willing to delve into details of a woman’s drinking behaviour in case it leads to other things they are unprepared for as HS1 highlighted:

It is quite conceivable that you could carry out screening and ABI in 5-10 minutes and do it appropriately and effectively and that has been shown in other settings. I suppose where additional time comes in is when you open up a kind of major issue. For example, a woman who have been drinking quite a lot and then a lot of it shift then to discuss about things that will impact on the baby that they may not be happy about (HS1).

All policy participants indicated that the number of women screening positive to hazardous and harmful alcohol consumption was low. These low numbers may prove to be a challenge to service in terms of numbers actually benefitting from the intervention.

The feedback from antenatal is that, they just couldn’t get, that what we’ve got anyway, is that they are screening everybody and they are not getting anybody saying that they are drinking. So that was the feedback that we received (SG2).

In terms of women’s self-reporting of what level they are drinking at during pregnancy, very few screen positive using a tool like TWEAK or T-ACE. So what the Boards are saying is, we are screening large numbers of women but actually very few are actually screening positive. So for them there is kind of real issue there in terms of the balance of where you might argue that the benefit to the few women that need the intervention might be great. There is a big effort that has to go in order to reach and benefit those few women. So they see it as kind of disproportionate effort (HS2).

The low numbers of women who may benefit from ABI may have implications for the delivery of the ABI, as midwives will rarely get the opportunity to practice what they learnt from the training.

170

However, they all agreed that the low numbers were expected for the reason:

The majority of women probably don’t drink, I mean there are high percentage of women who drink during pregnancy but the majority of women don’t drink and those who do drink, drink infrequently (HS1).

HS1 expressed subtle scepticism regarding the legitimacy of ABI in antenatal care settings, probably in acknowledgement of the low numbers of pregnant women who have received ABI to date. The good evidence base of ABI in other healthcare settings had been cited earlier by HS1 as a rationale for introducing it in antenatal care settings.

It was hoped that its successful implementation would help add on to it budding evidence base.

There is not a lot of evidence in there (antenatal) at the moment, so that was part of it as well, was to look at try and build the evidence...(SG1).

...but has been much more slower process because we don’t have that evidence based there to refer to (HS1).

Nevertheless, HS1 identified differences between the drinking habits of pregnant women and other health care populations that may account for the potential differences in the effectiveness of ABI among these groups.

The difficult with midwives doing it is, ABI is obviously targeted at women drinking hazardously and harmfully. The majority of women probably don’t drink... so ABI is not technically appropriate for a woman in pregnancy (HS1).

Another barrier was to do with the origin of the screening tools that are currently being used in antenatal care. All policy participants were in agreements that the wording was not ideal and the language sounded a bit alien to the Scottish culture. They were however, of the view that midwives could tailor the questions to women’s understanding.

171

If you take for instance TWEAK, because of its American origin and the way in which it kind of evolved, if you take that first question in TWEAK, “how many drinks does it take to make you feel high?” That terminology is not the kind of terminology that practitioners in Scotland will use and feel comfortable with using. So what we are trying to do here is to kind of contextualise it and say, well look, this is what it is trying to say and you could describe this to women in a slightly different way (HS2).

In this regard, for midwives to identify women drinking at hazardous and harmful levels correctly, their interpretation of the screening tools may be essential.

SG1 pointed out that the general acceptance of alcohol use in Scotland posed difficulty with introducing screening and ABI in Scotland health care system because it challenges societal norms.

There is always a cultural challenge, which is really general in whatever setting you are going to be in. Wherever you are raising questions around alcohol, you are completely challenging Scottish culture at the moment where alcohol fit into life in general, not for everybody but there is kind of culture there. So, that is always gonna be a challenge (SG1).

Chiaffarino et al. (2006) indicated that acceptance of alcohol in a society removes stigmatisation and promotes open discussions about women’s drinking habits. SG1 suggested that to some extent, ABI is challenging Scottish-drinking norms. However, it can also be argued that if alcohol is widely accepted in the society, then pregnant women could easily discuss their consumption with their midwives, enhancing identification of women for the ABI. Conversely, if guidelines and people criticize women for drinking in pregnancy, the opposite scenario may prevail.

5.9 Key features

The following programme theories (propositions) resulted from this chapter:

 The HEAT targets and KCND initiative may offer midwives regular opportunity to assess women drinking levels.

172

 Policies like KCND may facilitate early identification of alcohol use and intervention.

 Antenatal period is a good opportunity to screen and deliver ABI because women are already motivated to change drinking behaviour

 Training and supports have the potential to negate barriers and promote ABI delivery.

 Training and support may increase midwives knowledge about prenatal alcohol issues.

 Training and support raised the priority of the screening and ABI programme;

may assist midwives to improve their confidence and understanding of alcohol issues; it may ensure fidelity to screening and ABI delivery; and provide them with the relevant materials to undertake the screening and referral process.

 The level of priority accorded to ABI by midwives may be essential for its delivery in the midst of other competing issues.

 The amount of information to be provided to women at the booking may compromise the quality of screening and ABI delivery.

 Screening has been extended to also identify pre-pregnancy hazardous and harmful drinking to ensuring that all women who are at risk of drinking in pregnancy are covered.

 Delivery of ABI in antenatal care settings may be late regarding the health and safety of the fetus but there could be other benefits such as, subsequent reduction of maternal alcohol use.

173

 Midwives and pregnant women’s attitudes to drinking in pregnancy could determine the extent of acceptability of screening and the ABI in antenatal care settings.

 Low number of ABI deliveries means midwives confidence and motivational interviewing skills may reduce and this may influence quality of delivery over time.

 Strong relationships that develop in antenatal care settings between midwives and pregnant women may enhance ABI delivery.

 The continued relationship that midwives have with pregnant women in antenatal care may inadvertently cause pregnant women to provide socially desirable responses to alcohol screening.

 The mandate given to midwives to interpret validated screening tools for women understanding may have unexpected consequences.