Choices in Pregnancy

Routine Enquiry Approach

Choices in Pregnancy – A routine enquiry approach

‘When you think of alcoholics you have a vision of a down and out.'

Routine enquiry:

Removes the pressure on the midwife to ‘ask the right questions in the right way'
Starts to expand the sphere of responsibility for identifying individuals with problems
Has an ongoing impact on culture and attitudes
Has an instant effect on displacing sole responsibility and increasing confidence

We accept that drinking is a common normative behaviour in and around the reproductive cycle. Whilst we recognize that a large amount of research is still needed in this area and there is still no conclusive advice on ‘safe' levels of drinking in pregnancy, we feel it is sensible to develop a proactive approach to helping women make better choices about drinking when they are pregnant. With this in mind we recommended the development of an interactive information/assessment tool to identify personal and family drinking habits and attitudes. We were funded to develop, pilot and evaluate this new approach in 2006.

The project has produced a booklet of self-completion activities to be given to all newly identified pregnant women, introduced at a booking visit alongside other paperwork. The booklet is designed to be completed at home, possibly with a partner, returned to the next visit, and used to bring up areas for discussion. We have included details of support services and other resources where a woman can access advice and information anonymously. All the information and more is available through this website. Both interventions incorporate sections on smoking, domestic violence, stress etc.. to facilitate self referral.

The development of this tool will be informed by research findings on natural recovery and motivational enhancement. Natural recovery in this context is defined as the process of self-change from drinking or drug use with no contact with professional help. For many years this area of addiction research has been largely ignored by treatment professionals, mostly because they rarely come into contact with someone who has recovered on their own, but also because natural recovery does not comfortable fit with the idea of addiction as a disease. In the alcohol field however, the ratio of untreated to treated alcohol abusers has been estimated to range from 3:1 to 13:1. This ratio is even higher for smokers. When examined in the light of the research on self-change:

Addiction looks very different if you study it in the general population compared to treated cases. [Robins, 1993]

The study of self change is increasingly important in substance use, where not one treatment can be pointed to as having demonstrated a high rate of sustained recovery [Klingemann et al 2001].

In terms of examining self-change in pregnancy, there are a number of factors that are salient when deciding on how we can promote it in what is a highly sensitive yet motivated population. Research findings have identified four main drivers for self-change with clinical implications for treatment:

Cognitive evaluations
Affect-related reasons
Behavioral monitoring / actions
Social support from others

Female drinkers have been found to be more likely than male to use non-alcohol specific health care settings, particularly mental health services, and to report greater symptom severity. Women also have been found to seek non-traditional avenues of help such as general health and mental health care settings for dealing with their alcohol problems [Klingemann et al 2001]. We also know that identifying drinking and drug use in pregnancy is strongly influenced by societal factors, and any intervention developed needs to accept a number of things:

Women require anonymity & confidentiality - fear of stigma and labelling
Natural recovery is the most common route to change
Women may believe that their problems are ‘not serious enough'
Women want to do something about the problem ‘on their own'
Women are less likely to want to approach specialist services for help than generic services
Pregnancy and childrearing is a time to build new social networks

With these factors in mind, the development of a discreet intervention that is designed to promote and enable self-change whilst being delivered routinely through non-specialist community channels is highly appropriate.