Midwives’ engagement in smoking- and alcohol-prevention in prenatal care before and after the introduction of practice guidelines in Switzerland: comparison of survey findings from 2008 and 2018

There is a large body of evidence to show that cigarette smoking and alcohol consumption during pregnancy negatively impacts fetal health [1, 2]. Studies systematically report that smoking during pregnancy is associated with preterm delivery, low birth weight, and spontaneous abortion [3]. Similarly, higher levels of alcohol consumption in pregnancy is associated with negative birth outcomes and increased risk of neurodevelopmental disorders for the child [1, 4].

Since smoking and alcohol use related risks for prenatal and neonatal health are avoidable, national and international health institutions have increasingly emphasized the important role of healthcare professionals, especially midwives, in smoking and alcohol use prevention among pregnant women [5, 6]. Midwives care for women during and/or after pregnancy, and are thus well-positioned for screening the smoking and alcohol use habits of women, and observing their exposure to passive smoke. Moreover, through building trusting and supportive relationships, midwives can effectively educate pregnant women about relevant risks for the child and can facilitate positive changes to women’s behavioral patterns [7, 8]. Empirical evidence shows that in high-income countries, psychosocial interventions increase the rates of women who quit smoking during late pregnancy [9]. Further, counselling on smoking cessation has been shown to be particularly effective when it is used consistently throughout the course of pregnancy [10]. In accordance, health agencies across countries have developed specific guidelines for health professionals in order to strengthen their role in perinatal smoking and alcohol use prevention.

In 2005, a survey-based study commissioned by the Swiss Federal Office of Public Health (FOPH) revealed that around 10% of the pregnant women in Switzerland smoked daily, while 30% drank alcohol at least once per month, and 2.2% reported consuming at least four drinks on a single occasion at least once during pregnancy [11‐13]. Another study examined pregnant women’s alcohol use in 11 European countries and found that in Switzerland, alcohol consumption during pregnancy is higher (20.9% of women) than in most other studied countries, including Norway (4.1%), Sweden (7.2%), and Poland (9.7%) [14]. Furthermore, only around 66% of pregnant women reported having been screened for smoking during pregnancy and around 36% reported having received screening for alcohol consumption during prenatal care [11‐13], which suggests a lack of effective smoking and alcohol use prevention services in Switzerland.

In response to these figures and in accordance with the national strategy for the prevention of non-communicable diseases in Switzerland [15], the Swiss Midwives Association introduced the “Guideline on Screening and Counselling for prevention of cigarette smoking and alcohol consumption before, during, and after pregnancy” in 2011 (revised and updated version released in 2017). Its goal was to provide guidance for midwives’ everyday practice regarding screening and consultation on cigarette and alcohol consumption among women before, during and after pregnancy [16, 17]. The practice Guideline includes a decision tree to facilitate decision-making and integrates smoking and alcohol prevention into the midwives’ work routine suggesting the following action points: (1) Universal screening of pregnant women regarding smoking and alcohol use; (2) Informing all women about the smoking and alcohol use related risks for the child; (3) Recommending smoking cessation; (4) Recommending abstinence from alcohol during pregnancy; (5) Addressing the risks related to environmental smoke exposure; (6) Integrating counselling and/or intervention approaches including motivational interviewing [18] and the ‘5A’ approach [19]; and (7) Referrals to specialist care for women with heavier smoking and/or alcohol use habits [16, 17]. Similar guidelines have been implemented in other countries including the Netherlands [20, 21], Scotland [22], Australia [23], and Canada [24]. However, recent evaluation studies provide mixed findings regarding the extent with which they are implemented consistently [21‐27].

The aim of the current study was to evaluate the extent to which midwives increased their engagement in smoking and alcohol use preventive activities after the Guideline was introduced. To achieve this aim, we assessed the change in midwives’ screening and counselling practice in Switzerland, between 2008 (when the first survey with midwives was conducted, prior to the introduction of the Guideline) and 2018 (when a second survey was conducted including the same questions). Moreover, we examined changes in midwives’ awareness of smoking and alcohol consumption related risks for the child as well as their perceived barriers to effective smoking and alcohol use screening and prevention. As a further aim of the study, we examined the extent to which engagement in smoking and alcohol use prevention in 2018 was related to (a) whether midwives graduated before or after the introduction of the Guideline in 2011, (b) regional differences (i.e. between the French and German speaking regions in Switzerland), and (c) differences across work settings (i.e. working in hospitals versus being self-employed).

The present study aimed to evaluate the extent to which Swiss midwives increased their engagement in smoking and alcohol use prevention 7 years after the introduction of the Swiss Midwives Association’s Guideline on screening and counselling for prevention of cigarette smoking and alcohol consumption. To achieve our aim, we compared midwives’ engagement in smoking and alcohol prevention in prenatal care in 2008, before the Guideline of the Swiss Midwives Association was introduced, and in 2018. Further, we conducted analyses to explore the extent to which the observed differences among midwives in 2008 and 2018 were also subject to differences across regions, graduation years and work settings. Overall, in 2018, midwives appeared more aware of the risks of consuming even small quantities of cigarettes and alcohol for the unborn child. This was particularly pronounced in relation to alcohol use. However, engagement with smoking and alcohol consumption prevention remained rather stable at low levels particularly regarding more extensive intervention efforts, across the 10 years.

Overall, explaining the risks to pregnant women who smoke/ consume alcohol remained the most frequently reported prevention strategy (> 80%), while referring women who smoke to an expert, developing a quit or reduction plan with women who smoke/ consume alcohol, or providing women with information material remained at rather low levels despite an observed increase across the two study waves. This finding suggests that a large number of midwives were still rather reluctant to engage in more extensive smoking and alcohol use prevention interventions in 2018, which may be explained by the finding that despite the introduction of the Guideline, the midwives still considered their advice against smoking and alcohol use as relatively ineffective [7, 18, 19].

To our knowledge, the contents of the Guideline have been integrated into Swiss midwives’ formal training, through particular modules concerning smoking and alcohol consumption prevention among pregnant women and new mothers. However, the extent of training in the contents of the guidelines possibly differs across midwifery schools and regions of the country. Relatedly, we expected that the engagement in alcohol use and smoking prevention would differ according to whether midwives graduated before or after the introduction of the Guideline and between different work settings. Furthermore, we assumed that whether midwives work in a hospital or as self-employed would play a role, as contextual factors such as time pressure may differ. Still, our study showed that the emerging patterns appear to be largely consistent across regions, graduation periods and work settings, although there are few significant differences in specific screening strategies and in the reasons reported for not addressing smoking and alcohol use. Thus, the findings are only partially consistent with research in the Netherlands [25] suggesting that the implementation of smoking prevention counselling as well as the relative barriers acknowledged vary across professional groups. Also, they point to the importance of further exploring the reasons that prevent midwives in Switzerland from engaging more actively in smoking and alcohol use preventive strategies despite knowing the relevant risks.

A domain where we did find differences between work settings is the opinion that pregnant women tend to misreport their smoking and alcohol use habits. This barrier to effective screening was more often mentioned by midwives working in hospitals, who also often reported that shortage of time was a barrier to addressing smoking. As a recent study [22] showed, a relationship of trust between midwives and pregnant women facilitates more authentic and accurate disclosure of substance use behaviors. Therefore, apart from integrating routine screening of smoking and alcohol use in prenatal care, it is also important that hospital work routines allow midwives sufficient time to develop a trusting relationship with pregnant women, which in turn may also improve effective substance use prevention.

Further, in terms of knowledge of the Guideline, our findings did not show any significant differences between midwives who graduated before and after the introduction of the Guideline in 2011. This indicates that the extent to which the Guideline has been integrated into midwives’ training during the 7 years since its introduction has not been sufficient to meet the desired changes in midwives’ practice. Emphasizing smoking and alcohol prevention in midwives’ basic training should be combined with further educational activities that highlight the necessity of the Guideline and its implementation, as well as with raising midwives’ awareness of the impact of their own advice [8].

Further, activities that aim to reduce midwives’ tendency to believe that pregnant women underreport their smoking and alcohol use habits, and to increase midwives’ motivation to actively engage with prevention [21, 29] might also be useful. Accordingly, our findings suggest that efforts should also focus on increasing midwives’ knowledge and skills to use the decision-making aids outlined in the Guideline. This could involve training in motivational interviewing and engagement in discussions around sensitive topics [21] (e.g. personal life information or substance abuse), as well as the integration of simple applications in midwives’ everyday practice, including digital applications or conventional tools like printed screening questionnaires, decision trees, and checklists. These would enable midwives to conduct the smoking and alcohol use screening more efficiently and to set quitting goals and behavior change interventions in a more structured way [29‐31].

In sum, our findings indicate that the Guideline has not been particularly effective in increasing midwives’ engagement in smoking and alcohol consumption prevention, since the changes between 2008 and 2018 were not large. Despite being more aware of the risks related to smoking and alcohol use in pregnancy, midwives still do not engage in smoking and alcohol use prevention in a consistent manner. This is particularly alarming given the increased prevalence of smoking and alcohol use during pregnancy in Switzerland [32, 33].

The present findings should be seen in the light of certain limitations. First, there were differences regarding the study design and data collection between the two study waves. In 2008, midwives with a record in the phone book completed a hardcopy questionnaire received via regular mail, while in 2018 the members of the Swiss Midwives Association were contacted by email and asked to complete the questionnaire online. Although the background information regarding the samples look similar between the two measurement time points (e.g. similar shares of participants were working in hospitals) it remains possible that there were differences between the two samples that have not been considered.

Second, in the current naturalistic study it was not possible to study a control group unexposed to the Guideline. Therefore, it is not possible to determine whether changes were actually due to the introduction of the Guideline by the Swiss Midwives Association. Third, due to anonymity of the responses it was not possible to match answers of midwives between 2008 and 2018, although it can be assumed that the samples were partly overlapping. Fourth, the use of an even-numbered Likert scale for certain items did not allow ambiguous answers to indicate an undecided response (i.e. potentially undecided respondents were forced to decide for one side in some items). Finally, it is possible that some of the answers were influenced by memory related biases or social desirability. Future research might benefit from integrating both the midwives’ as well as the clients’ reports of midwives’ smoking and alcohol use prevention in order to account for potential response biases.

In conclusion, the findings indicate that 7 years after the introduction of the Guideline by the Swiss Midwives Association in 2011, midwives appear more aware of the risks of smoking and alcohol use during pregnancy. However, systematic engagement with preventive activities across the whole course of pregnancy such as assisting women in the elaboration of a plan to stop smoking/alcohol use remained relatively infrequent. This suggests that the effect of the Guideline in changing midwives’ working practice has been limited and that future research should explore the reasons explaining the stable lack of engagement particularly in more extensive interventions. Further, our findings suggest that there should be greater emphasis on increasing midwives’ familiarity with the Guideline, increasing midwives’ self-efficacy, and improving the way in which clinical tools are available to them across different work settings, particularly in hospitals. To increase the effectiveness of counselling, midwives’ vocational training may include practical training in intervention techniques such as motivational interviewing, and hospitals may adopt longer consulting sessions to enable midwives to develop a patient-centered approach and to build a relationship of trust with their clients and potentially their partners [34]. Further, conventional (e.g. printed leaflets) and digital means (e.g. screening texts or apps) may also contribute to the more structured and systematic engagement of the midwives in screening and preventive activities before, during and after the pregnancy period.