Alcohol consumption during pregnancy : how do we separate myth from reality?

The overall aim of this thesis, consisting of five studies, was to examine what midwives do when they encounter women with alcohol use during pregnancy; to evaluate and implement screening instruments aimed at identifying at an early stage women with a hazardous level of alcohol consumption; and to provide a basis for preventive measures. The overall objective was to avoid prenatal alcohol exposure. For Study I a questionnaire was constructed comprising twenty-eight structured and unstructured questions. In the other four studies the Alcohol Use Disorders Identification Test (AUDIT) was used. AUDIT is a screening instrument intended for early identification of hazardous or harmful alcohol consumption (see appendix 2). In Study III and IV a more extensive, interview based technique was also used, "Timeline Followback" (TLFB), which is an internationally established assessment instrument that measures past alcohol consumption, regarding both amount and pattern of drinking (see appendix 3 ). In Study III blood samples were taken and analysed using routine analyses for liver enzymes (GGT, AST, ALT), the established alcohol marker carbohydrate-deficient transferrin (CDT), and mean corpuscular volume of red blood cells (MCV). Study I shows that the midwives had difficulties in identifying women at risk with regard to alcohol. Study II indicates that there are simple screening instruments that can help the midwives to identify women in the risk zone regarding alcohol consumption. There is a tendency that women who screen positive prior to pregnancy are more apt to expose their fetus to alcohol during pregnancy. Seventeen per cent of the women reported that they had a level of alcohol consumption in the year before pregnancy high enough to cause a risk of future physical or mental problems for themselves. Thirty per cent of the women reported some alcohol consumption during pregnancy, most of them at low levels. In Study III women attending the antenatal clinic (ANC) for the first time because of pregnancy were interviewed. The results are in accord with those from Study II regarding alcohol consumption prior to pregnancy. Regarding consumption during pregnancy, the study shows that considerably more than 30% (87%) of the women had consumed some alcohol during the first trimester. The blood samples taken in order to identify harmful alcohol consumption turned out to be of very little use as the women with elevated test results turned out to be physically ill and not high consumers of alcohol. In Study IV systematic screening was implemented among regular midwives at the ANC. The results show that there is no difference in sensitivity between the ANC midwives and the research midwives. With one day of training the midwives managed to use the screening instruments without difficulty and to identify women in the risk zone. Study V is a repetition of Study I to analyse potential developments over time. It replicated the finding that a group of women drank during pregnancy, but in comparison to Study I, women who were high consumers the year before pregnancy showed an increased tendency to reduce alcohol consumption during pregnancy. In summary the results show that: 1) Current routine screening methods for alcohol consumption before and during pregnancy identify few or very few women and children in the risk zone; 2) Well-established screening methods are available and are able to detect considerably more cases than current methods; 3) Minimal extra resources are required in order to carry out screening at the ANC; 4) The patients appear to be satisfied with the increased information and screening; 5) Possibly, a greater focus on the risks of alcohol during pregnancy influences pregnant women and especially high consumers to reduce consumption