Building a case for a standardised antenatal alcohol screening programme in the UK

Howlett, Helen Kathryn (2021) Building a case for a standardised antenatal alcohol screening programme in the UK. Doctoral thesis, Northumbria University.

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Abstract

Background:
A paucity of antenatal alcohol consumption prevalence rates in the UK and limited guidance around the implementation of antenatal screening practices led to the inception of my research within the field. In particular, the need to raise awareness of the risks of Prenatal Alcohol Exposure (PAE) and FASD with UK health professionals and the wider public. As a midwife researcher I identified that addressing this gap in knowledge was urgently required to evaluate and improve antenatal alcohol practices and services.

Introduction:
My published papers follow a logical and sustained sequence of investigations to address this deficit, and consequently make an independent and original contribution to knowledge and understanding. Adopting an inductive approach, I initially examined the utility of self-report in relation to blood biomarkers to improve existing screening methods. Expanding the scope of my research to examine patient and healthcare professional’s expectations, knowledge and experience in relation to alcohol in pregnancy and the condition of Fetal Alcohol Spectrum Disorder (FASD). Finally, I consolidated this work by evaluating existing practices and services across the North-east and North Cumbria to inform future policy and make service recommendations.

Aim:
The aim of my PhD was to investigate the feasibility and clinical effectiveness of antenatal alcohol screening for pregnant women, their partners and clinicians; and to evaluate a regional antenatal alcohol service provision in maternity practice.

Design and Methodology:
I have taken a pragmatic approach and utilised a variety of methods to fully address my research objectives. A systematic review was undertaken comparing the diagnostic accuracy of blood biomarker analysis to maternal self-report in the detection of antenatal alcohol consumption. Retrospective anonymous surveillance using clinical audit methodology and blood biomarker analysis was employed to obtain epidemiological prevalence data regarding antenatal alcohol use. Surveys were used to understand patient understanding and attitudes to antenatal alcohol screening and healthcare professionals’ knowledge and experience of alcohol and FASD in practice. An evaluation of current alcohol prevention, screening and treatment service provision in maternity care practices and services in the North East and North Cumbria using content analysis was undertaken to inform strategic planning for the Local Maternity System.

Results:
The six publications present a logical and inductive progression of enquiry, culminating in the presentation of a body of evidence which validates antenatal alcohol screening as feasible, acceptable and a recognised public health priority which should be integral to routine clinical practice. However, the effectiveness of the screening methods varied, and more research is required into blood biomarker analysis in pregnancy. Training and education requirements were also identified in healthcare professionals and the public. In response, the prioritisation of antenatal alcohol screening and the standardisation of best practices are recognised needs in UK maternity services. As a measure of success, I have received national and local recognition of my research which is now informing and changing clinical practice.

Discussion:

My main knowledge contributions are:

• Production of empirical evidence that antenatal alcohol screening can effectively identify women at risk, thereby facilitating intervention to improve both maternal and infant health outcomes.

• The demonstrated feasibility and acceptability of establishing routine antenatal alcohol screening also has the potential to determine reliable UK alcohol in pregnancy prevalence rates to inform future healthcare strategies.

• Self-report is the cheapest and most accessible method of screening, but blood biomarkers may also be beneficial and cost-effective in the long-term.

• FASD and alcohol in pregnancy training is urgently required for UK healthcare professionals.

• Alcohol reduction in pregnancy should be made an urgent public health priority in UK maternity services to improve health outcomes across the life-course.

• Standardised UK patient pathways involving alcohol screening and management practices are required, and the sharing of best practices will facilitate referrals and support regardless of location.

• The implementation of these recommendations requires appropriate leadership, commissioning and training strategies.

Conclusions:
My research has helped raised awareness and improved current practices relating to alcohol in pregnancy in the UK. The findings include original regional prevalence rates and have identified potential antenatal alcohol screening and management strategies. My evidence-based recommendations are already informing national Public Health England recommendations, NICE consultations, multidisciplinary training and service improvement initiatives. This new evidence has demonstrated the need for further inquiry into the challenging and complex issues surrounding alcohol harm reduction in pregnancy.

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