24. Pregnancy and perinatal care
How to support women and other people who are pregnant to reduce or stop their alcohol use to reduce risks for the fetus and mother. It covers information and advice, multi-agency care planning, specialist treatment for alcohol dependence and support in the perinatal period.
Guidance for maternity services, alcohol treatment services and other healthcare professionals
Alcohol can affect fetal development throughout pregnancy and can cause fetal alcohol spectrum disorder and perinatal complications.
Problem alcohol and drug use, deprivation and multiple disadvantage all increase the risk of a woman or person dying during pregnancy and up to a year after giving birth. Services should be designed to reduce these health inequalities.
Maternity, alcohol treatment and other healthcare professionals should support women and other people who are pregnant to reduce or stop their alcohol use as quickly and safely as possible. This reduces the ongoing exposure to the fetus and the risk and severity of future disability, as well as risks for the mother.
National Institute for Health and Care Excellence (NICE) quality standard Fetal alcohol spectrum disorder (QS204) recommends that:
Midwives and other healthcare professionals should give women clear and consistent advice on avoiding alcohol throughout pregnancy, and explain the benefits of this, including preventing fetal alcohol spectrum disorder (FASD) and reducing the risks of low birth weight, preterm birth and the baby being small for gestational age.
Midwives and other healthcare professionals should advise women and other people who are (or who could be) alcohol dependent not to stop drinking suddenly as this can increase risk to them and to the fetus. They should rapidly refer women or people who are or could be alcohol dependent for a specialist assessment for medically assisted alcohol withdrawal.
In line with NICE QS204, maternity staff should ask women and other people who are pregnant about their alcohol use at antenatal appointments throughout their pregnancy and record this.
Maternity staff should rapidly refer pregnant women and other people who are pregnant who are drinking heavily, are alcohol dependent, or have a history of problem alcohol use to a specialist alcohol treatment service. They should also refer them to the specialist maternity pathway for substance misuse or complex needs.
Women and other people who drink heavily during their pregnancy are often vulnerable and experience multiple disadvantage. Healthcare professionals need to use a non-judgemental and trauma-informed approach and prioritise helping them to engage in antenatal care, alcohol treatment, safeguarding and other services.
Professionals should use a multidisciplinary and multi-agency approach to co-ordinate care during pregnancy and the perinatal period for the mother or parent, baby and father or partner.
Where there is risk of significant harm to the unborn child or baby, professionals must make a child safeguarding (child protection) referral in line with national legislation and guidance and organisational procedures. Infants aged 2 years and under have the highest risk of mortality and serious harm compared to children in other age groups.
When a woman or other person who is pregnant is alcohol dependent, there are specific considerations to provide maternity care during pregnancy, at the birth and in the early postnatal period. The baby will need to be monitored by neonatal paediatricians after the birth and may require specialist interventions.
Where there has been significant prenatal alcohol exposure, the child will need ongoing monitoring. If children do not meet developmental milestones, clinicians should refer them through local FASD diagnostic and support pathways or to the national FASD clinic if there is no local pathway.
Parental alcohol use is an established risk factor for sudden unexpected deaths in infancy. All services should be able to give accurate advice on safe sleeping for babies.
Healthcare professionals, including practitioners in alcohol treatment services, should offer pre-conception information and advice on contraception to women and other people of child-bearing age with problem alcohol use. Where there has been an alcohol exposed pregnancy, they should offer advice on contraception soon after the birth of the baby or refer women and other people to sexual health services for this advice.
Maternity services should ensure that maternity staff have training in the chief medical officer’s guidelines on drinking in pregnancy, fetal alcohol syndrome awareness and in alcohol brief interventions. Alcohol treatment services should ensure their staff also have training in these areas.
Guidance for alcohol treatment services
Alcohol treatment services should prioritise referrals for women and people who are pregnant or have a baby, even if they are not currently drinking. This is to reduce risks to the fetus (and after birth, the baby) and to the mother.
Alcohol treatment services should offer flexible support and remove any barriers to engagement. For example, they should offer home visits where possible.
Alcohol treatment services should recognise that pregnancy and the perinatal period is a vulnerable time. During the perinatal period, women and other people have an increased risk of returning to problem alcohol use, mental health problems and domestic abuse. Alcohol treatment services should offer frequent and regular psychosocial support after the birth and extend the period of support where necessary. They should also refer women and other people to appropriate services, including perinatal mental health services.
There are specific considerations for alcohol treatment clinicians when they provide pharmacological interventions during pregnancy and during breastfeeding. See section 10.6.4 in chapter 10 for more information about these considerations.
This chapter includes guidance on:
- providing information on the risks of alcohol use during pregnancy for all pregnant women and other people who are pregnant
- identification, support and treatment for women and other people with alcohol dependence or who drink heavily during pregnancy
The guidance is for clinicians and practitioners working with women and other people during pregnancy and the perinatal period. The term ‘perinatal period’ used in this chapter means pregnancy and up to one year after birth.
The guidance is relevant for all practitioners working across maternity services, alcohol treatment services and other health services unless there is a statement saying that it is specifically for maternity services or for alcohol treatment services.
The UK has the fourth highest estimated prevalence of alcohol use during pregnancy in the world (Popova and others, 2017). Alcohol is a teratogen, which means it can affect fetal development throughout pregnancy and cause birth defects and perinatal complications. NICE QS204 states that alcohol use in pregnancy increases the risks of:
- low birth weight
- preterm birth
- the baby being small for gestational age
Research has also shown that alcohol use in pregnancy has a significant risk of miscarriage in the first trimester (Kesmodel and others, 2002).
Prenatal alcohol exposure (PAE), which occurs when a woman or person who is pregnant drinks alcohol during their pregnancy, can result in FASD. FASD is a term that describes the wide range of outcomes that can result from PAE, including lifelong physical, cognitive, behavioural, and mental health difficulties. FASD can affect facial features and growth. However, it is now well-recognised in research and in clinical practice that the facial features (described in national guidance like NICE QS204 and the Scottish Intercollegiate Guidelines Network (SIGN) guideline156 as ‘sentinel’ features) are only found in a minority of babies with FASD.
Reducing fetal alcohol exposure reduces the risk of FASD. However, it is not possible to quantify a ‘safe’ level of alcohol use. The UK chief medical officers’ advice on low risk drinking is that women who are pregnant or think they could become pregnant should completely avoid alcohol.
The report Saving Lives, Improving Mothers’ Care 2024 (by Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK)) found that 9% of the women who died during or up to 6 weeks after pregnancy in the UK in 2020 to 2022 had severe and multiple disadvantages, such as:
- mental health diagnosis
- alcohol and drug use
- domestic abuse
Deaths from mental health-related causes continue to account for a large proportion (34%) of deaths occurring between 6 weeks and a year after the end of pregnancy with deaths due to problem substance use and other psychiatric causes the leading cause of deaths in this period.
There are differences in maternal mortality rates between White women and women from other ethnic backgrounds, including that:
- Black women are 2.9 times more likely to die than White women
- Asian women are 1.7 times more likely to die than White women
- women of mixed ethnicity are 1.3 times more likely to die than White women
Also, women living in the most deprived areas continue to have maternal mortality rates twice that of women living in the least deprived areas.
It is vital that services are designed to respond to these increased risks, and staff are aware of them. Staff need to work together to provide supportive personalised multidisciplinary care to reduce these health inequalities.
24.5.1 Principles
The principles for working with women and other people who are pregnant are to:
- provide personalised care during pregnancy and in the perinatal period
- support women and other people who are pregnant to reduce (and when safe to stop) their alcohol use as quickly as possible to reduce the ongoing exposure to the fetus and the risk and severity of future disability
- support women and other people who are pregnant in a non-judgemental, non-stigmatising way
These principles are based on consensus of the alcohol guidelines development group.
24.5.2 Providing advice on avoiding alcohol use in pregnancy
NICE QS204 recommends that:
Midwives and other healthcare professionals should give women clear and consistent advice on avoiding alcohol throughout pregnancy, and explain the benefits of avoiding alcohol, including preventing fetal alcohol spectrum disorder (FASD) and reducing the risks of low birth weight, preterm birth and the baby being small for gestational age.
It also recommends that:
They provide verbal and written advice, based on the UK chief medical officers’ low-risk drinking guidelines, that the safest approach is to avoid drinking any alcohol during pregnancy. This includes information that the risk of harm to the baby is likely to be low if only small amounts of alcohol have been consumed but that further drinking should be avoided. They use a non-judgemental approach, discuss any concerns, and provide support and information according to the woman’s needs, which may include a structured conversation, help to stop drinking through a brief intervention or referral to specialist services.
Midwives, alcohol treatment practitioners, and other healthcare professionals should advise women and other people who are pregnant and who are (or who may be) alcohol dependent not to stop drinking suddenly. This is because withdrawal complications risk harm to the fetus and the mother or parent. Professionals should rapidly refer them to specialist alcohol treatment to be assessed for medically assisted alcohol withdrawal, so they can stop drinking safely (see section 24.13.1 on assessment for alcohol treatment during pregnancy).
The verbal and written information and advice that services provide should be easy to understand and available in accessible formats including easy read and in a range of languages that reflect the demographics of the population. Services should arrange for independent interpreters (not a family member or friend) to be available for women and other people who do not speak English as their first language.
24.5.3 Asking women and other people who are pregnant about their alcohol use
NICE QS204 recommends that pregnant women are asked about their alcohol use throughout their pregnancy and this is recorded:
Talking about and recording alcohol consumption during pregnancy allows personalised discussions about the risks of alcohol use as part of routine healthcare throughout pregnancy. It also gives opportunities to offer tailored support and interventions if the woman wishes to cut down or stop drinking. This may reduce risks and improve outcomes for the mother and baby. Women should be asked about their alcohol consumption in a sensitive, non-judgemental way. Women who wish to discuss their alcohol use should be asked about the quantity, frequency, and pattern of drinking, and this should be documented in their maternity records. This information may also help support early diagnosis and treatment for children with fetal alcohol spectrum disorder (FASD).
Early diagnosis and treatment of FASD can improve a child’s future outcome.
24.5.4 Screening tools
Some services use screening tools when they ask women and other people about their alcohol use. Screening tools are one way of introducing a conversation about alcohol. But if services are using screening tools, these should be used to support the conversation, not replace it. Forming a trusting relationship where the person feels able to talk about their alcohol use is vital. Conversations based on the principles of motivational interviewing can help people to talk about their drinking and consider change.
You can find guidance on motivational interviewing in chapter 5.5.6 on psychosocial interventions.
The advice on levels of health risk that accompanies most alcohol screening tools is based on the UK chief medical officers’ low risk drinking guidelines, which refer to health risk for adults. Risk to the fetus is likely to begin at much lower levels than risk to adults. Although reducing fetal alcohol exposure reduces the risk of FASD, it is not possible to quantify a ‘safe’ level of alcohol use during pregnancy. The guidelines refer to research that shows the risks of low birth weight, preterm birth and being small for gestational age may all be increased if mothers drink above 1 to 2 units per day during pregnancy.
Currently there is only limited evidence for the use of screening tools in pregnancy.
In a systematic review of alcohol use screening tools, the following screening tools were found to be helpful in screening for risky drinking (Burns and others, 2010):
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Alcohol use disorders identification test for consumption (AUDIT-C), available in the guidance Alcohol use screening tests, is a test to quickly identify alcohol harm.
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T-ACE (an acronym based on the subjects of the screening questions: tolerance, annoyance, cut-down, ‘eye-opener’), a tool used to screen for risky alcohol use in pregnant women.
However, the review’s authors recommended caution, saying that there should be further evaluations of questionnaires for prenatal alcohol consumption. Other research has shown that the effectiveness of these tools may also vary according to cultural context (Russell, 1994). In services that use screening tools, staff should be trained to use them and to interpret the scores to inform an appropriate intervention.
Scotland’s SIGN guideline 156 recommends that services consider using AUDIT-C, TWEAK and T-ACE screening tools, but also says there are potential limitations to these tools.
Guidance in section 24.6 is for staff in maternity services. Maternity staff should also read guidance in the rest of this chapter except section 24.13, which is specific to staff in alcohol treatment services.
Maternity staff and other healthcare professionals should offer women and other people who use alcohol during pregnancy an intervention based on an individual assessment of the level of their alcohol use and other relevant risk factors.
Interventions could include the following.
24.6.1 People with very low levels (low risk) of alcohol use
For very low levels of alcohol use and no other risk factors, services should provide appropriate information and guidance to support decision making. They should then continue to review the woman or person’s alcohol use and advise that avoiding alcohol is safest for the fetus and the mother or parent.
24.6.2 People with previous problem alcohol use or co-occurring mental health or physical health conditions
For women or other people who are pregnant who have had previous problems with alcohol use, or who are drinking above very low levels and have additional needs such as a mental health condition, services should offer a:
- brief alcohol intervention (staff should be trained to offer this)
- referral to community alcohol treatment service for psychosocial support
Services should refer the person to a specialist midwife or substance misuse midwife (through local specialist maternity pathways) and other relevant services.
24.6.3 People who may be alcohol dependent
For women and other people who are pregnant and have alcohol dependence, possible alcohol dependence or who are drinking heavily, services should advise them not to stop drinking suddenly, because of the risk of harm to the fetus and themselves.
Services should:
- refer the woman or person and help them to quickly access specialist alcohol treatment
- refer the woman or person to a specialist midwife or substance misuse midwife (through local specialist maternity pathways)
- provide a contact number for a named specialist midwife or doctor
- refer the woman or person to other relevant services, such as children’s social care for safeguarding, domestic abuse or mental health
Women and other people who are pregnant will often be involved with several services, so it’s important that they can have a consistent relationship with healthcare professionals in those services and that their care is well co-ordinated.
24.6.4 Alcohol as a coping strategy
Healthcare professionals should be aware that women or other people who are pregnant who have a history of using alcohol as a coping strategy are at significantly increased risk from stressful events during pregnancy even if they are not using alcohol regularly. For example, stressful events could include:
- relationship conflict
- domestic abuse
- safeguarding assessments
- pregnancy-related problems
Signposting women or other people who are pregnant to additional support such as mental health support or domestic abuse services and referring them to community alcohol treatment services can help and encourage them to develop alternative self-support strategies.
24.7.1 Principles
The following principles are for staff in maternity services, alcohol treatment services, other healthcare staff (midwives, nurses, doctors, health visitors) and staff in other relevant services.
These principles are based on consensus of the alcohol guidelines development group.
Make every effort to provide accessible care and to engage women and other people who are pregnant and who are alcohol dependent or drinking heavily. This could be women or other people in antenatal care, alcohol treatment and other relevant services.
Recognise that women and other people who are pregnant and who are alcohol dependent or drinking heavily:
- are often vulnerable
- experience multiple disadvantage
- can have past or current experience of trauma
So, you should use a trauma-informed approach and treat them with respect. You can read more about this in the Working definition of trauma-informed practice.
A roadmap for creating trauma-informed and responsive change: guidance for organisations, systems and workforces in Scotland also provides extensive guidance on implementing a trauma-informed approach.
Make sure that women and other people who are pregnant have the information they need to make decisions and to give consent, in line with the:
- General Medical Council’s guidance on decision making and consent
- Nursing and Midwifery Council’s code on professional standards of practice and behaviour
- 2015 Montgomery ruling
Act to safeguard the unborn child and newborn baby in line with national legislation and organisational safeguarding procedures. The duty to act to protect a child at risk of significant harm includes the unborn child (see annex 1 on legislation and guidance).
Make sure the woman or person who is pregnant can access a comprehensive assessment of their needs, including:
- alcohol use
- substance use (including illicit drugs, prescription medication, whether prescribed or obtained illicitly, and over the counter medication or herbal medication)
- smoking
- domestic abuse
- mental health
- housing need
Take a multidisciplinary, multi-agency approach involving maternity services, alcohol treatment services, health visiting and other relevant services such as children’s social care, mental health (including perinatal mental health teams) and domestic abuse throughout pregnancy, at birth and after birth.
Involve fathers, partners and family members, unless it is unsafe or inappropriate to do so.
Support fathers, partners and family members in their own right, even where it is not appropriate for them to be involved in the care of the pregnant woman or person.
24.7.2 Understanding and addressing vulnerability and multiple disadvantage
Women and other people who are pregnant who have alcohol dependence or who are drinking heavily during pregnancy are likely to be vulnerable and experience multiple disadvantage (also referred to as multiple and complex needs). NICE clinical guideline Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors (CG110) notes that vulnerable women who experience multiple disadvantage are less likely to access and adhere to antenatal care and guidance.
It is vital for the health of the woman or person who is pregnant and the health of the fetus that maternity services, alcohol treatment services, health visitors and other healthcare and social care services can engage and effectively support them. How effectively they are engaged with these services will depend on staff understanding the complex psychological and social factors vulnerable women and other people who are pregnant experience and responding appropriately.
Teenage pregnancies are generally (although not always) unplanned, and they are associated with higher risk. So, services need to treat teenage girls and young women and other young people who are pregnant to reduce these risks where possible and provide support throughout the antenatal and postnatal period.
Many areas have specific antenatal and postnatal pathways for teenage and young parents which may be through the named safeguarding midwife or through a dedicated midwife for teenage parents. Practitioners must act in line with national and organisational child safeguarding guidance, considering safeguarding needs of the mother or parent and the unborn child.
Note that sexual activity with children under 13 years is always illegal and always requires a child protection referral.
24.7.3 Supporting and maintaining engagement
Barriers to getting help
Women and other people who are pregnant who are alcohol dependent or who are drinking heavily can experience anxieties that deter them from seeking help or engaging with support, including:
- problems in forming trusting relationships because of past or current trauma
- fear or guilt about the impact of their alcohol use on their unborn child
- fear that their baby may be removed into care
- anxieties based on previous bad experiences of services
Vulnerable women and other people might be unaware of available help. They may also experience other barriers to accessing services, including:
- inflexible appointment times
- geographically inaccessible services
- service information that is not accessible or easy to understand
- stigma (feeling judged by staff and others accessing services)
- lack of staff with competence to work with vulnerable women and other people
Recent migrants, refugees and asylum seekers may experience language or cultural barriers or have fears about their immigration status. Some vulnerable migrants might have no recourse to public funds and need support in understanding their entitlements.
How services can improve access to support and treatment
Services and staff should work to reduce barriers to engagement by:
- building trusting relationships
- having straightforward access and flexible engagement processes
- providing clear information that encourages shared decision making
Services can build trusting relationships by making sure their staff are trauma-informed and culturally competent. They should provide continuity of care between midwifery and health visiting services with a consistent team and named practitioner that co-ordinates care during pregnancy, birth and in the postnatal period.
You can find more guidance on continuity of care in NICE guideline Antenatal care (NG201) and guidance ‘Care continuity between midwifery and health visiting services: principles for practice’ in Supporting public health: children, young people and families.
Antenatal and alcohol treatment services should work to reduce barriers to access by:
- timing appointments to suit the person
- meeting women and other people where they live or at another service they attend
- offering to pay transport costs
Staff should take a proactive and persistent approach, including sending friendly reminder texts or calls for appointments and missed appointments.
Services should provide clear information and advice, including about:
- the risks of alcohol use in pregnancy
- the risks to women and other people with alcohol dependence of stopping drinking suddenly
- accessing their services and other relevant services provided elsewhere
- what to expect after they give birth, including medical care the baby may need
- any potential involvement of child safeguarding services
All information you provide to the woman or person should be accessible and tailored to their particular needs, including considering:
- first language
- literacy
- sensory impairment
- cognitive impairment
- neurodiversity
You can find more guidance on providing information to women and other people during pregnancy in NICE NG201 and CG110.
24.7.4 Safeguarding
Services must make a safeguarding referral, in line with national legislation and organisational safeguarding procedures, where there:
- is a significant risk of harm to the unborn child due to ongoing heavy drinking or alcohol dependence during pregnancy
- are other issues of concern, such as mental health conditions or domestic abuse
Early referral to child safeguarding services helps the agencies to co-ordinate care for the mother and baby and to safeguard the baby after birth. When considering safeguarding referrals, practitioners should consider that reviews of child deaths and serious harm show that infants between 0 and 2 years are the age group at highest risk (NSPCC, 2023). Services should work together to maximise the chance of the ideal outcome of the mother or parent and baby safely remaining together.
You can find more information on child safeguarding guidance (which includes unborn children) in annex 1.
If the safeguarding referral is against the parent’s wishes, the practitioner making the referral should explain the reason for the referral and that there is a legal requirement for them to do so (unless informing the parent would put a child at further risk) and respond sensitively to the parent’s concerns. The practitioner should try to maintain remote or in-person contact with the parent to support them and review their wellbeing. Women and other people who have had other children removed may be particularly vulnerable.
24.7.5 Multidisciplinary, multi-agency assessment and care planning
All services involved with the woman or person during pregnancy and the perinatal period will need to work together to co-ordinate care and share information appropriately. This will include joint multidisciplinary and multi-agency assessment and care planning, including safeguarding.
Maternity and alcohol treatment services working together
Access to maternity and alcohol treatment services, and engagement with them, is essential for a safe and healthy pregnancy for the woman or person and the fetus. Commissioners, strategic managers and clinical leads for maternity and alcohol treatment services should agree 2-way referral pathways and services should have working relationships with each other. Vulnerable women or other people who are pregnant may also need urgent access to services for co-occurring conditions such as mental health, or social factors like domestic abuse or housing.
The optimal care for women or other people who are pregnant who have problem alcohol use is a specialist multidisciplinary clinic for alcohol and drug use in pregnancy, provided by maternity and specialist alcohol treatment services working together. Where this is not available locally, services will need to co-ordinate multidisciplinary, multi-agency care and appropriate information-sharing arrangements.
What multidisciplinary, multi-agency care planning involves
Multidisciplinary, multi-agency care planning should cover pregnancy, birth and the perinatal period. Maternity and alcohol treatment services need to work together and:
- be clear about the role of each agency and which professional is responsible for each agreed task
- assess, manage and review risks as they change throughout the pregnancy, at the birth and in the perinatal period
- plan maternity care and alcohol treatment interventions
- make sure they include safeguarding (child safeguarding services will lead on the safeguarding plan)
- involve the GP
- address co-occurring conditions including substance use, tobacco use, mental health, physical health complications and social factors such as domestic abuse or housing
- make sure referrals and support to access appropriate agencies are made without any unnecessary delays
- arrange support for parenting during pregnancy and in the perinatal period
- include support for the father or partner in their own right where this is needed
- wherever possible, fully involve the woman or person in the assessment and care planning, taking into account their views on their own needs and those of their unborn child
- keep the woman or person informed of any changes to plans
- involve fathers, partners or family members in assessment and care planning, unless it is unsafe or inappropriate to do so
- make clear agreements between services about sharing information and regularly review and update the information
- share information on attendance, missed appointments and alcohol consumption with members of the team
- align service care plans and consider developing one integrated care plan
- consider developing shared electronic notes which can be seen by relevant professionals
It is always best practice to ask consent to share information. However, you can share information without consent if the unborn or child is at risk of significant harm.
If the mother loses a baby through miscarriage or death, or there are plans to remove the baby into care, you will need to provide support for the parents such as perinatal mental health or bereavement support.
24.7.6 Involving fathers, partners and family
Services should assess strengths and any risks in the family network as part of the multi-agency assessment and child safeguarding services will usually lead on this. Family members can contribute to assessment and care planning, where it is appropriate and with the woman or other person’s consent. Family members can play an important role in supporting the woman or person to stop or reduce their alcohol use during pregnancy and the perinatal period.
Fathers or partners can contribute to supporting the woman or person where there are no indications of risk to them or to the fetus. NICE NG201 recommends that maternity staff ask all women and other people about domestic abuse in a kind, sensitive manner at the first antenatal (booking) appointment, or at the earliest opportunity when she is alone.
Staff should make a careful assessment of the level of any risk posed by the partner and make a child safeguarding referral where there is a risk to the unborn child and the mother or parent. They should work with domestic abuse services to reduce risk and follow relevant legislation and organisational procedures on domestic abuse. The partner should not be involved in assessment and planning for the woman or person’s needs in situations where they pose a risk of perpetrating domestic abuse.
Services should offer the father or partner access to information and support where they have a need. If the father or partner also has problem alcohol or drug use, services should encourage them to access alcohol or drug treatment. The Department for Education report Children’s needs: parenting capacity (second edition) suggests an association between fathers who drink heavily and increased risk of babies with lower birth weight or heart defects, and spontaneous abortion and neonatal deaths are associated with heavy drinking of either parent. Services should also provide or refer fathers or partners for stop smoking support.
Multidisciplinary, multi-agency care planning should continue after the birth. There is guidance on this in section 24.9.1.
Guidance in section 24.8 is for maternity services. This guidance should be considered alongside the following NICE guidelines and, for Scotland, SIGN clinical guideline:
24.8.1 Additional antenatal appointments and care
NICE NG201 recommends additional or longer antenatal appointments if needed, depending on the woman or other person’s medical, social, and emotional needs. This is relevant for women or other people who are pregnant and are alcohol dependent or who are drinking heavily during pregnancy.
If there has been PAE, you should arrange for the woman or other person to have extra growth scans in addition to the 20-week fetal anomaly scan.
Evidence of fetal growth restriction could be due to a variety of reasons, including:
- poor mental health
- poor maternal diet
- perinatal alcohol exposure
- substance use
- maternal health problems, for example with blood pressure
Where there is PAE and poor fetal growth, you should share this information with neonatal paediatric teams for postnatal assessment, because PAE as a cause of poor fetal growth can be overlooked.
Maternity staff should be aware that liver damage due to long term alcohol use or hepatitis C in mothers may increase the risk of transmission of hepatitis C from to the fetus during pregnancy or the baby at or after birth. If the woman or person has a history of injecting drug use, services should offer to test for blood-borne viruses and explain why that is important.
24.8.2 Birth plan
Wherever possible, maternity services should work with women and other people who are pregnant who have alcohol dependence or are drinking heavily, to devise a carefully considered specialist labour and birth plan.
The plan should include and address:
- risk of seizures, especially in association with hypertension
- risk of arriving in an intoxicated state in labour, which may be due to concerns about inadequate pain relief or for other reasons
- safeguarding arrangements
24.8.3 The newborn baby with PAE
Newborn infants with PAE will require monitoring by a specialist neonatal paediatric team. Increased risks to newborn infants include (but are not limited to) intrauterine growth restriction which can lead to complications, such as hypoglycaemia (low blood sugar).
If mothers or parents are alcohol dependent or have recently used alcohol before delivery (within the previous 24 hours), then the baby might not respond normally at the time of delivery and in the early postnatal period. This can lead to an increased chance of needing resuscitation support at the birth.
This can also affect the baby’s metabolism and cause drowsiness, resulting in poor feeding. Both these factors increase the risk of hypoglycaemia. Specialist neonatal paediatric teams should test for this regularly according to local protocols. The baby may need feeding support with the help of a nasogastric tube until they are able to feed normally.
Where there has been PAE throughout pregnancy, the baby may show evidence of acute withdrawal in the first couple of days after birth and may develop seizures consistent with acute alcohol withdrawal. Clinicians should follow local protocols for treating and monitoring the baby.
Complex neurodevelopmental problems resulting from FASD may not appear until many years later, although a small number of babies could show features consistent with FASD. If there has been significant PAE, or babies have clinical features consistent with FASD, clinicians working with the baby should identify the baby as being ‘at risk of FASD due to PAE’ and refer them for follow-up using local pathways.
If a child is adopted and later needs to be assessed for developmental problems, information on PAE should be considered as part of the assessment.
When considering safeguarding issues concerning the newborn infant, clinicians must act in line with child safeguarding legislation and guidance (see section 24.7.4 on safeguarding above). They should carry out any agreed actions recorded in the safeguarding birth plan and share all relevant information with local children’s social care services.
Section 24.9 contains guidance for all health and social care practitioners, including health visitors and staff in alcohol treatment services.
24.9.1 After the birth: multidisciplinary, multi-agency care planning
Multidisciplinary care plans for women or other people who are alcohol dependent or drink harmfully (including those who stop drinking during pregnancy) should cover the period immediately after the birth and for the first year of the baby’s life.
Local services should continue to work together to offer mothers or parents and babies (and fathers or partners) tailored support. These include:
- maternity services
- alcohol treatment services
- health visiting services
- safeguarding services
- GPs and primary care and smoking cessation services
- other relevant services
Support needs can include support for the woman or parent’s own mental health, and for the developing relationship between mother or parent and baby and help to manage conflict between parents. This support could come from:
- the perinatal mental health team
- health visitors
- adult mental health services
- other relevant services
In England, referrals to the perinatal mental health team will be fast-tracked for mothers or parents with complex needs, including alcohol and drug problems.
Services should work together to provide appropriate support to maximise the chance of the ideal outcome of the mother and baby safely remaining together.
24.9.2 Ongoing monitoring of the child’s development
If you have concerns that children born to mothers or parents with problem alcohol use during their pregnancy have delayed or atypical development outcomes, you should arrange for regular monitoring and review of their developmental milestones. This can be done by a health practitioner such as a health visitor, school nurse or GP.
If children do not meet their developmental milestones, you should refer them through local FASD diagnostic and support pathways. This will usually mean referring the child to local services for children with established neurodevelopmental issues. You should sensitively discuss any need for assessment with the parents in a non-judgemental way. Where local pathways do not exist, you can refer children and adults to the national clinic for FASD (UK wide).
Section 24.10 contains guidance for healthcare practitioners, including those in alcohol treatment services.
To reduce the risk of alcohol-exposed pregnancies, clinicians and healthcare practitioners (including those in alcohol treatment services) should advise women and other people who are pregnant about the risks of PAE, including FASD.
Services should provide information on the risks and benefits of various contraception options, including long-acting reversible contraception (LARC), to women of child-bearing age and other people who may become pregnant. Services can also refer them to sexual health services for this advice.
If a woman or person has given birth after an alcohol exposed pregnancy, clinicians should discuss contraception with them soon after the birth to reduce the risk of further PAE. Clinicians should be sensitive to where this advice would not be appropriate.
There should be referral pathways in place to sexual health services, including an enhanced pathway for women or other people who are assessed as being at risk of an alcohol exposed pregnancy.
The guidance in s section 24.11 is for all staff in healthcare services, including maternity staff and health visitors, staff in alcohol treatment services, and in children’s services.
24.11.1 Sudden unexpected deaths in infancy
Parental alcohol use is an established risk factor for sudden unexpected deaths in infancy (SUDI). The national 2020 Child Safeguarding Practice Review Panel report Safeguarding children at risk from sudden unexpected infant death found that almost all of the 14 deaths they analysed involved parents co-sleeping in unsafe sleep environments with infants, often when the parents had consumed alcohol or drugs. The finding was consistent with findings from other reviews, including an analysis of 27 serious case reviews of sudden unexplained deaths in infancy that showed the majority of deaths involved the combination of parental problem alcohol or drug use and co-sleeping (parents and babies sleeping in the same bed or on the same sofa or armchair) (Garstang and Sidebotham, 2018). All services should provide consistent advice on safe sleeping arrangements using the NHS advice on reducing the risk of sudden infant death syndrome or equivalent national guidance. This is everyone’s responsibility, not just one service or practitioner.
24.11.2 Maternal mental health and deaths
Problem alcohol and drug use and multiple disadvantage (including mental health conditions and domestic abuse) are significant risk factors for maternal death up to a year after birth (see section 24.4 on risks to women during or up to a year after pregnancy above). The 2021 MBRRACE-UK report Saving Lives, Improving Mothers’ Care - 2017 to 2019 made the following recommendation for action by all health professionals:
“Women with substance misuse are often more vulnerable and at greater risk of relapse in the postnatal period, even if they have shown improvement in pregnancy. Ensure they are reviewed for re-engagement in the early postpartum period where they have been involved with addictions services in the immediate preconception period or during pregnancy.”
The 2021 MBRRACE-UK report also includes the following 2 recommendations:
New expressions or acts of violent self-harm are ‘red flag’ symptoms and should always be regarded seriously. New and persistent expressions of incompetency as a mother or estrangement from the infant are ‘red flag’ symptoms and may be indicators of significant depressive disorder.
Loss of a child, either by miscarriage, stillbirth and neonatal death or by the child being taken into care increases vulnerability to mental illness for the mother and she should receive additional monitoring and support.
You can find guidance on self-harm in the NICE guideline Self-harm: assessment, management and preventing recurrence (NG225).
The guidance in section 24.12 is for midwives working in antenatal care and for practitioners in alcohol treatment services.
NICE QS204 recommends that commissioners should make sure that midwives providing antenatal care:
- are aware of the risks to the fetus of drinking alcohol in pregnancy and the advice in the UK chief medical officers’ low-risk drinking guidelines on alcohol consumption in pregnancy
- have training on FASD awareness
- have training in alcohol brief interventions (see chapter 3 for guidance on alcohol brief interventions)
The alcohol clinical guidelines development group recommend that alcohol treatment services make sure their practitioners also have training in the above areas.
NICE CG110 recommends that training should be given to:
- healthcare professionals on multi-agency needs assessment and national guidelines on information sharing
- healthcare professionals on the social and psychological needs of women with alcohol or drug problems
- healthcare staff and non-clinical staff, such as receptionists, on how to communicate sensitively with women with alcohol or drug problems
The alcohol clinical guidelines development group also recommend that:
- training should include trauma-informed practice and awareness-raising about stigma experienced by women and other people who are pregnant and have problem alcohol use, particularly those who have previously had children removed from their care (see section 2.2.2 on stigma in chapter 2 on principles of care)
- healthcare practitioners’ knowledge could be enhanced through multi-agency training where maternity care staff, alcohol treatment staff and social workers share their expertise
The guidance in section 24.13 is for alcohol treatment services. Alcohol treatment clinicians and practitioners should also read the guidance in the rest of this chapter (except section 24.6 and 24.8 which are specific to maternity services).
You should read this section together with section 24.7 on supporting women and other people with alcohol dependence or problem alcohol use who are pregnant.
24.13.1 Assessment for alcohol treatment during pregnancy
You should read this section along with chapter 4 on assessment and treatment and recovery planning, which provides guidance on specialist assessment for alcohol treatment. This section includes additional guidance that is specific to assessment during pregnancy and the perinatal period.
Prioritising women and other people who are pregnant
Women and other people who are pregnant should be regarded as a priority for alcohol treatment and services should fast track them into treatment, engaging them as early as possible. Services should treat women and other people who are pregnant as a priority for both assessment and treatment interventions. Any delay in starting treatment may increase the risk to the mother or parent and the fetus.
Services should urgently assess the needs of the pregnant woman or person, even if they:
- are currently drinking below the usual threshold for accessing an assessment
- have a history of problem alcohol use but are not currently drinking
This is to reduce risks to the fetus and the mother or parent, and to ensure they have appropriate support during a vulnerable period.
Women and other people may also become pregnant while in treatment, so alcohol treatment services should offer pregnancy tests and make it clear these are available. The guidance below is relevant whether the woman or person who is pregnant is a new referral to the service or is already engaged in treatment.
However, it is important to advise anyone who is pregnant or think they could be, not to stop suddenly as this could cause harm to them or the baby. The assessor should arrange an assessment for medically assisted withdrawal as soon as possible.
Initial assessment
At the initial assessment, the assessor should:
- seek to build a trusting relationship using a trauma-informed approach
- discuss antenatal care and make an urgent referral through the local maternity services pathway, if the pregnant woman or person is not engaged with this already
- speak to their GP, maternity services and other relevant services
- make a safeguarding (child protection) referral in line with legislation and organisational safeguarding procedures, where there may be a risk of significant harm to the unborn child (see section 24.7.4 on safeguarding)
- refer the woman or person to sexual health services or to their GP for advice and counselling if they are considering a termination
- provide accessible information and advice on the risks of alcohol use during pregnancy, including FASD, as set out in section 24.5 on principles and interventions for working with all women and other people who are pregnant
- take actions to support and maintain the woman or person’s engagement with treatment (see section 24.7.3)
- involve fathers, partners or family members unless it is not safe or appropriate (see section 24.7.6 on partner and family involvement)
Alcohol treatment services should have effective pathways with maternity and midwifery services. In many areas, this will be through their local specialist midwife services or a named substance misuse midwife. If the pregnant woman or person is not yet engaged with antenatal care, the alcohol treatment practitioner should rapidly refer them through these pathways. If there are no local specialist or substance use maternity pathways, the alcohol treatment practitioner should refer the pregnant woman or person to the local named safeguarding midwife or locally designated maternity pathway for problem alcohol or drug use.
Assessing for medically assisted withdrawal and health conditions
If the woman or person is (or may possibly be) alcohol dependent, a specialist clinician in the alcohol treatment service should assess them for medically assisted withdrawal as quickly as possible and refer them for this where required. The plan for medically assisted withdrawal and for subsequent care should involve the obstetrician (see section 24.13.2 on pharmacological interventions below). The obstetrician should discuss with the woman or person:
- the risks and benefits of this intervention
- how these risks and benefits apply to them
- the necessary information for them to make an informed decision about the treatment
Clinicians should consider specialist inpatient medically assisted withdrawal for women and other people who are pregnant, because these settings should have the necessary facilities and staff competencies. The multi-agency team, including the obstetrician, should also assess with the woman or person whether it would be appropriate for them to begin residential rehabilitation after medically assisted withdrawal.
The specialist alcohol treatment clinician should make a thorough assessment of the person’s:
- alcohol use
- substance use (including illicit drug use, prescription medication, whether prescribed or obtained illicitly, and over the counter medication or herbal medicines)
- tobacco use
- physical health
- mental health needs
They should make referrals to appropriate health services if needed and provide (or refer to) smoking cessation advice and support where needed.
The clinician should provide ongoing monitoring of the woman or person’s physical and mental health and share information with:
- maternity services
- primary and secondary care health services
- safeguarding services
- other relevant services
24.13.2 Pharmacological interventions for alcohol dependence during pregnancy
You can find guidance on pharmacological interventions during pregnancy and during breastfeeding in section 10.6.4 in chapter 10 on pharmacological interventions.
You should read section 10.6.4 if you are considering prescribing for medically assisted withdrawal during pregnancy or during breastfeeding. It includes guidance on medications that should not be used during pregnancy for safety reasons.
Medication for relapse prevention is not normally recommended for someone who is pregnant or breastfeeding, but you should read guidance on this in section 10.6.4 of chapter 10 for further consideration.
Assessing social factors including domestic abuse
The main assessor should make sure they assess social factors, including domestic abuse, since pregnancy is a risk factor for domestic abuse. During pregnancy, domestic abuse may increase or begin for the first time. So, assessors, specialist clinicians and keyworkers should be vigilant and ask sensitively about domestic abuse at assessment and subsequent reviews and make referrals where necessary.
See section 24.7.6 on domestic abuse and also guidance on assessing domestic abuse in section 4.9.12 in chapter 4 on assessment and treatment and recovery planning.
There is more comprehensive guidance in chapter 22 on people experiencing or perpetrating domestic abuse. The assessor should also be aware that women or other people who have experienced sexual trauma may find pregnancy and giving birth stressful and potentially retraumatising. Staff should take particular care to use a trauma-informed approach for all aspects of the woman’s care.
24.13.3 Multi-agency assessment and treatment and recovery planning
When carrying out the assessment and developing a personalised treatment and recovery plan with the woman or person, alcohol treatment clinicians and practitioners should make referrals where appropriate. They should also work jointly with other relevant services and contribute to a multidisciplinary, multi-agency approach. You should follow the guidance in section 24.7.5 on a multidisciplinary and multi-agency approach.
It is particularly important that treatment and recovery plans and risk management plans are frequently reviewed. This is because needs and risks could change significantly throughout pregnancy and after the birth.
The personalised alcohol treatment and recovery plan should be aligned with other plans including antenatal plans and safeguarding plans. Services should share relevant information with one another if the needs or risks change.
24.13.4 Assessment and treatment and recovery planning after the birth
Services should recognise that the perinatal period (pregnancy and a year after the birth) can be a vulnerable time where the woman or person may be at greater risk of returning to problem alcohol use and at increased risk of mental health problems. Even if a woman or person did not drink during their pregnancy, she may be at greater risk of returning to problem alcohol use after the birth of the baby.
The alcohol treatment keyworker should seek to re-engage the woman or person soon after the birth and continue to review their alcohol use and offer support regularly. The alcohol treatment service should offer flexible support. For example, the service should consider offering home visits in the early weeks or months after the birth.
The alcohol treatment service should offer ongoing psychosocial support for as long as the woman or person needs it. Services should not stop offering support based on a policy that sets standard limits for length of time in treatment. Decisions about ending alcohol treatment should be part of multidisciplinary, multi-agency care planning and review and should fully involve the woman or person.
The alcohol treatment practitioner should work with other agencies in the multi-agency team to make sure the woman or person can access appropriate support for their mental health and for parenting where needed. For example, this could be support from the perinatal mental health team, health visitors or from children’s services and family hubs. You should read the guidance in section 24.7.7 on this.
Services should make sure that staff are aware of and contribute to managing other increased risks during the perinatal period. This is because:
- alcohol is a significant risk factor for sudden unexpected deaths in infants (see section 24.11.1)
- problem alcohol use is a risk factor for maternal deaths in the first year after birth (see section 24.4)
- safeguarding reviews show that infants aged 0 to 2 years are the highest risk group for death and serious harm (NSPCC, 2023)
Where there has been an alcohol exposed pregnancy, services should offer advice on contraception soon after the birth of the baby or refer the woman or person to sexual health services for this advice (see section 24.10).
In some areas there may be specialist services for children, parents and families affected by parental problem alcohol or drug use. Where this is the case, the woman or person should be introduced to this service and offered the option of engaging with it.
Peer support workers who are mothers or parents with past problem alcohol use may be supportive for women and other people during the perinatal period.
24.13.5 Women or other people presenting to the service in the first year after giving birth
Women or other people presenting to the alcohol treatment service for the first time in the year after giving birth should be treated as a priority and offered assessment and treatment as quickly as possible. This is because of the increased risks to mother or parent and baby during this period. Assessment and treatment planning should then follow the recommendations above. If the baby is at risk of significant harm, the service must make a child safeguarding referral and follow national safeguarding guidance and organisational procedures (see annex 1 for information on national legislation and guidance).
24.13.6 Psychosocial interventions
The alcohol treatment service keyworker should offer structured support at regular intervals during pregnancy, and in the year after the birth, to make sure the woman or person is adequately supported around risk of relapse at a vulnerable time.
Where the alcohol treatment service has trained psychologists, they should offer psychological treatments, if the assessment shows these would be appropriate. You can find guidance on psychosocial interventions in chapter 5.
The alcohol treatment service should co-ordinate the psychosocial support they provide with other services in the multi-agency team and provide advocacy where necessary. You can find further information on multi-agency working in section 24.7.5 and 24.7.7.
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