4. 0 Chapter Four: Methodological discussions and methods
5.5 Clinical settings
This theme was identified deductively. From the realistic framework, it was anticipated that the culture, rules and routines within antenatal care may be different in comparison to other settings, like primary care in which screening and ABIs are well established. I therefore explored from policy perspective the extent to which these factors had been considered in the implementation approach.
5.5.1 Antenatal care
All policy participants were of the view that midwives’ varied opinions and attitudes towards alcohol use may have implications for screening and the delivery of ABI (see section 6.4 for midwives attitudes). However, they all commended midwives for their enthusiastic approach to the ABI initiative. Generally, they were of the opinion that midwives felt it was part of their role to help women in various aspects of their health during pregnancy, including controlling their alcohol use.
So, they (midwives) saw it as being consistent with their practice, sort of the kind of thing you expect midwives to be discussing. They saw it, you know within the context of the SWHMR (Scottish Women-Held Maternity Records) notes and that kind of approach being quite consistent to be integrated and embedded within that (HS2).
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However, later HS2 expressed an alternate view from the comments above when asked to give an opinion of the suitability of screening and ABI in antenatal care:
I think there is a definite sort of ambivalence within midwifery about whether it is the best, you know an appropriate setting for alcohol screening and intervention given the range of other things they will say are equally, if not higher in terms of importance, yeah. They do certainly report that they feel that they are putting in an awful lot of effort at a time they can use to discuss other things (HS2).
This view was probably based on initial feedback from midwives following delivering ABI in practice. Therefore, it could be inferred that not all midwives were totally convinced about the usefulness of screening and ABI in antenatal care. It could be argued that, midwives attitudes would had been different if the number of women who needed the ABI could account for the resources invested. HS2 by making reference to
‘given the range of other things that are equally important’ indicates that as compared to other issues that need to be discussed at the booking, screening and ABI seemed less of a priority for midwives. This suggests that given the amount of information midwives have to provide to women at the booking, the quality of screening and fidelity to delivery of the ABI may be compromised. There is also the possibility that pregnant women may struggle to comprehend the considerable amount of information provided to them within a short space of time, which may have consequences on how well they are able to utilize the skills gained from ABI to effect positive drinking behaviour change.
5.5.2 Timing of ABI delivery
The time to intervene on alcohol use in pregnancy is important to consider because the period that alcohol is consumed in pregnancy is directly related to type and extent of adverse fetal outcomes (Ornoy and Ergaz, 2010). Policy participants were particularly apprehensive about the timing of delivery of ABI, and were concerned about the fact
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that women may have drunk alcohol during pregnancy by the time they come for their first booking appointment.
…this is it, it is where doing ABI in antenatal stage is too late because traditionally the majority of women would have seen their GP or their midwife at 12 weeks, generally in their first appointment and at that point if they have been drinking hazardously or harmfully or even more extremely than that, then the damage to the unborn baby is more likely to be done by then, in the early stages. So the effect of ABI at that point is probably fairly redundant (HS1).
HS1 assertion above suggested that ABI might not be beneficial for the unborn child of a woman who drank at higher levels in her first trimester since drinking in the first trimester could be associated with increased fetal risk and this view is supported by the review in chapter two.
Participants suggested that the opportunities pregnancy present was one of the reasons for targeting antenatal care settings. This is because the prenatal period presents a window of opportunity where women are assumed to be motivated to change negative health behaviours (Nilsen, 2009).
Why the focus has been on antenatal is purely because there is a captive audience there and all women regardless of their normal engagement with health services, generally well engage with the health service when they are pregnant at some stage so that would seem to be an opportunity to tackle them at that point (HS1).
...and it is a time that women might actually be motivated to change, it is also a time where, women if they have been drinking prior to becoming pregnant and haven’t planned to become pregnant might be a bit concern about a potential harm that might have been done to the baby in that early stage of pregnancy (HS2).
Interestingly, policy participants acknowledged the possibility of ABI being delivered in pre-pregnancy services like family planning clinics where it is more likely to have greater impact than in antenatal care settings.
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The alternative will be to do ABI at a family planning clinic or somewhere else whether women’s clinic or a GP surgery, where a woman is indicating she is going to try for a baby; or when she is going to go off the contraceptive pill; or something at that stage where obviously you can make a much bigger and more in terms of preventing the drinking becoming hazardous or harmful; or at a point where it is going to affect the conception of the baby (HS1).
I actually think maybe getting some of that information to women at the time when they are not pregnant is equally important and actually after pregnancy as well (HS2).
Opportunistically, the prenatal period seemed to be a good time to elicit health behaviour change, yet policy participants also acknowledged that active behaviour change strategies would have greater merits if they could be done pre-pregnancy and could be further enhanced during pregnancy.
5.5.3 Interpersonal relationships
Policy participants thought that the reason why midwives rather than GPs were asked to screen and deliver the ABI was as a result of policy change as well as an opportunity for midwives to establish good social relationships with women at early stage in their pregnancy.
There is a new policy for maternity called keeping childbirth natural and dynamic and the ethos of that policy is to make pregnant women’s first point of contact always the midwife. So naturally, it makes sense to ask midwives to do the ABI. The midwives themselves are also able to kind of build up a rapport with women over time with a relationship (HS1).
The screening and ABI, are meant to be carried out at the booking appointment. Policy participants suggested that both midwives and pregnant women are keen to protect the good social relationship that exists within antenatal care settings. In this regard, HS1 was of the view that, generally women are often unwilling to disclose their exact drinking levels at early stage of the relationship with their midwives. Participant SG2 also highlighted that midwives are equally careful to sustain good relationships with
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their clients.
...women are reluctant to divulge information. They might get looked upon negatively by their midwife especially at the first appointment. So particularly alcohol consumption with all the negative associations that are with alcohol consumption in pregnancy, women are reluctant to divulge that to the midwife for fear of kind of a breakdown of that relationship (HS1).
In terms of relationship, they (midwives) are very cautious about not ruining that relationship. Because, it takes a while to build up rapport with individual women and I remember being referred to it as 'the straw that could break the camel’s back'. If they bring that in, obviously since it is a sensitive matter as you said, so it is raising it at the right time and going about it in appropriate way...(SG2)
HS1’s reference to the fact that women ‘might get looked upon negatively’ reflects the ingrained societal norm of disapproval of women drinking in pregnancy. If women know that they may be seen by, the same midwife throughout their pregnancy and possibly beyond, they might prefer to maintain the relationship with their midwives, and intentionally or inadvertently provide socially desirable answers to health screening questionnaires (see section 7.10.1 for pregnant women’s account). Midwives are also having to negotiate this sensitive relationship, trying to build up trust and establish rapport. They have to balance supporting women they have just met, usually for the first time and deal with problem behaviours without destroying the relationship they plan to have with them (see section 6.8.2 for midwives findings).
HS2 articulated that sensitive issues are better discussed in well established relationships and this attribute may be absent during the booking appointment.
These are sensitive issues and one might argue that they are best discussed when a practitioner has an opportunity to develop a bit of trust and a relationship with a patient. And if that screening and potentially ABI delivery is done at the very first you know booking appointment, well you haven’t had that opportunity to build that kind of trust and relationship. Different from a
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doctor/GP-patient relationship where even if you visit your GP, you know reasonably frequently, you still kind of know them and they know you. It might be different from midwife and pregnant woman relationship, I think (HS2).
HS2 acknowledged the potential difference in relationships that occurs in primary care and antenatal care (potential differences between health care settings discussed in chapter three). This relationships difference suggests that there may be underlying differences in how ABI operate within these two settings. This is because the principles of ABI, and for that matter motivational interviewing strategy, rely strongly on established rapport between a practitioner and a client and the supposed bond that develops in antenatal care has the potential to enhance its delivery and subsequent follow-up. Yet, it is unclear where the direction of influence would be when ABI is delivered at the booking appointment when the relationship is fairly new and undeveloped.