A Good Start- Pamphlet from the Swedish National Institute of Public Health (2009)

Alcohol Policy in Sweden

Between 1996  and 2004, alcohol consumption in Sweden increased by 30% from approximately 8 to 10.4 litres per person and year. This was attributed partly to Sweden’s entry into the European Union (EU) in 1995 which led to a weakening of some areas of alcohol policy such as limits on private imports of alcohol and high alcohol taxes.

Sweden continues to have a national retailing monopoly called Systembolaget. The minimum purchase age at Systembolaget is 20 years, but people can drink at age 18 in restaurants and bars.

In 2009, overall rates had declined to about 9.5 litres per person and year. In general, Swedish men drink roughly twice as much as women in the same age category. Survey data suggests that approximately 6% of pregnant women in Sweden drink at least once during their pregnancy.

Brief Interventions in Prenatal Care

In Sweden, all pregnant women receive free prenatal care by midwives. Usually, women will have 8-10 visits with their midwife over the course of their pregnancy.

In the early 2000s, standard prenatal care in Sweden involved a meeting between a midwife and her patient during week 10–12 of the pregnancy. This visit included a question about a woman’s current frequency of drinking which was recorded in her file. Women were advised to abstain from drinking during pregnancy, if at all possible.

Shifting Policy Directions

Because of the difficulties of implementing policies based on controlling the price and availability of alcohol (which have been shown to be extremely effective) following EU entry, the Swedish government decided to shift their policy efforts.

The Risk Drinking Project was a national government initiative carried out from 2004 to 2010. The focus of the project was to encourage healthcare professionals to raise the issue of alcohol with their patients to support reducing risky drinking.

The project focused on all areas of healthcare including routine primary, child, maternity and occupational health care. It emphasized the use of motivational interviewing and promoting health professionals’ behavior change. “The Risk Drinking Project’s objective is for questions about drinking habits to have a natural place in everyday healthcare.” (Swedish National Institute of Public Health, 2010, p. 8)

Midwives and the Risk Drinking Project

Different approaches to brief interventions by healthcare professionals were adopted depending on the setting. Midwives in maternity health care adopted the use of the AUDIT screening form. However, this was more as a pedagogic tool and basis for discussion.

Rather than asking about a pregnant woman’s drinking during pregnancy, the project introduced a modified routine whereby a woman fills out the AUDIT questionnaire concerning her alcohol use in the year preceding her pregnancy. (This has been shown in research to be an important predictor for drinking during pregnancy). The AUDIT results then provided the basis for a discussion between the midwife and her patient.

Midwives reportedly supported this shift in practice. Using the AUDIT in this way was seen as a way of avoiding direct questions about self-reported alcohol use during pregnancy and allowed for a gentle entry way into the subject.

Changes in Prenatal Care

The two graphs below show changes in practice between 2006 and 2009.

The proportion of midwives who considered themselves to have very good or good knowledge in identifying patients with risky alcohol consumption increased from 72 to 92 per cent between 2006 and 2009.

The proportion of midwives who used forms to assess hazardous alcohol consumption increased dramatically between 2006 and 2009. In all regions except three, a minimum of 90 per cent of the midwives used forms in 2009.

A Good Start

In 2009, the Swedish National Institute of Public Health developed an 8-page pamphlet on alcohol and pregnancy for use in prenatal care called “A Good Start.” The pamphlet has an abstinence message: “It is best to abstain from alcohol completely whilst you are pregnant or planning to become pregnant.”

It covers fetal development, discusses situations in which women might be expected to drink alcohol, mentions partner drinking and support, provides reasons for refusing offers of alcohol, and includes a recipe for a mocktail.

For more on FASD prevention in Europe, check out earlier posts:

 

References

Nilsen P, Skagerstro¨m, J, Rahmqvist M, Hultgren E, Blomberg M. (2012). Alcohol prevention in Swedish antenatal care: effectiveness and perceptions of the Risk Drinking project counseling model. Acta Obstetricia Gynecologica Scandinavica, 91. DOI: 10.1111/j.1600-0412.2012.01402.x.

Nilsen, P., Wahlin, S., and Heather, N. (2011). Implementing Brief Interventions in Health Care: Lessons Learned from the Swedish Risk Drinking Project. International Journal of Environmental Research and Public Health, 3609-3627. Download free full-text from here.

Swedish National Institute of Public Health. (2010). Alcohol issues in daily healthcare. The Risk Drinking Project – background, strategy and results. Download from here.

Swedish National Institute of Public Health. (2009). A Good Start pamphlet. Available to download in Swedish, English and other languages from here.