Maternity & Midwifery Forum

Increasing confidence levels in alcohol and pregnancy conversations

By Joanna Buckard, Director of Innovation, and Katie Liddle, midwife and research and project officer, at National FASD

The messages around drinking alcohol in pregnancy have often been confusing, leaving maternity staff unclear about what is best advice. Joanna Buckard, Director of Innovation, and Katie Liddle, midwife and research and project officer, at National FASD explain the current guidance and share new resources available to help support maternity staff.


Following new policies, new resources on alcohol and pregnancy help maternity teams ensure healthier pregnancies.  The new NICE Quality Standard (QS204) (2022) on FASD, calls on service providers, especially maternity services, to: “ensure that midwives and other healthcare professionals providing antenatal care are aware of the risks to the fetus of drinking alcohol in pregnancy, and have training on FASD awareness and alcohol brief interventions. They ensure that antenatal appointments include verbal and written advice not to consume alcohol in pregnancy, based on the UK Chief Medical Officers’ low-risk drinking guidelines.” (Quality standard 1)

This and other recent policy changes require a fresh look at an old issue, and a new Alcohol and Pregnancy toolkit that includes innovative resources and a free e-course, is being launched to provide hands-on resources to help maternity teams.

It is important to get these conversations right because alcohol in pregnancy risks infertility, miscarriage, stillbirth, and Fetal Alcohol Spectrum Disorder (FASD), which is lifelong damage to the brain and body that affects more people than autism.

Call to action

National FASD is calling for midwives and the wider maternity team to recognise their unique position to make a difference and reduce harm caused by prenatal alcohol exposure. We are calling for management teams and commissioners to put into place better structures to fulfil the standards set out by NICE QS204. According to O’Brien (2022), “NHS England has a legal duty to take [NICE Quality Standards] into account in the discharge of its quality improvement duties. NHS organisations locally should take them fully into account in designing services that meet the needs of their local populations.” We want to ensure that maternity teams are given high quality training and have access to expert-reviewed resources to make it easier for them to tackle this agenda. We want to ensure that maternity teams are given high quality training and have access to expert-reviewed tools to make it easier for them to tackle this agenda.

The background

As someone who has been delivering multiagency and specialist midwives training for nearly two decades, I have seen consistent confusion in the UK over alcohol use in pregnancy: Can you drink? How much can you drink? Is it just the beginning when it’s unsafe? There are a variety of reasons that have led to the confusion including mixed messaging from health, a lack of public-health campaigns about the issue, opinion-led media coverage and older information being passed on from family and friends.

Whenever alcohol and pregnancy is talked-about stout is one of the most commonly mentioned ideas, ‘My Grandma said to have stout, it’s good for iron isn’t it?’. Yet the alcohol in the drink is not considered and many types of stout only have very modest levels of iron.

Over time there has been media coverage about research which was reported in a way that suggested low-level exposure was safe, lacking the nuances of the subject, or about the benefits of anti-oxidants in red wine and more recently that the abstinence message is patronising and patriarchal. Too often these articles fail to include expert opinion about the risk of harm caused by prenatal alcohol exposure (PAE).

Guidance came from the Chief Medical Officers in 2016 that: ‘If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all’. However, many healthcare practitioners were unaware of the change in guidance and were still quoting the older guidance from NICE (2008) that stated that pregnant women should avoid alcohol for the first three months of pregnancy and then they could have 1-2 units once or twice a week. This guidance from NICE was not removed until December 2018 ahead of NICE accepting the Scottish Intercollegiate Guidelines Network SIGN 156 (2019) the first UK guideline on Fetal Alcohol Spectrum Disorder (FASD).

Risk of harm

Alcohol is a teratogen, a substance capable of affecting embryonic and fetal development and can lead to miscarriage, premature birth, still birth and FASD.

FASD is a complex lifelong neurodevelopmental disorder which has 428 conditions that co-occur (Popova et al., 2016). FASD, is above all severe neurological impairment. It is a lot more common than may be perceived by the general public. In 2021 McCarthy et al conducted the UK’s first gold standard prevalence study which has shown that 2-4% of young people have FASD – a rate higher than autism. However, unlike autism FASD is preventable.

It is estimated that 41% of women drink alcohol in pregnancy in the UK, this puts us at the 4th highest in the world (Popova et al., 2017). The lack of public health messaging or lessons in school about the risks of PAE and FASD means that some pregnant women are attending their booking appointment and can be unaware of the CMOs’ guidance. Around 45% of pregnancies are unplanned (PHE, 2018) and 77% of women drink alcohol (NHS Digital, 2019) which means that prior to being given any information about PAE they could already have an alcohol-exposed pregnancy.

Many healthcare professionals acknowledge that they have not had sufficient information on the guidelines, the harm caused by PAE or about FASD which has led to a lack of confidence in how to talk to pregnant women about alcohol and how to answer the questions and concerns that women may have (Smith et al., 2021; Schölin et al., 2021).

New policies are game changers.

A range of updated publications from SIGN (2019), PHE (2020), DHSC (2021) and NICE (2022) has meant that all the major bodies are now singing from the same song-sheet in relation to PAE.

In 2022, NICE released ‘Quality Standard 204’ which recognised the need for improved services for FASD prevention, recognition, diagnosis and support in all Integrated Care Systems and Health Boards. It identifies midwives and maternity teams as a key part of FASD prevention by stating that healthcare professionals should be giving information about the risk of harm caused by prenatal alcohol exposure, asking about alcohol use in pregnancy and accurately recording this in the health record. Midwives and the wider maternity team are uniquely positioned to support expectant mothers to make informed decisions about alcohol use and implement the standards from NICE QS204 and other recent publications. Research conducted by OnePoll on behalf of National FASD, found that 85% of women expect and rely upon midwives and other healthcare professionals to provide the latest information about the risks of alcohol in pregnancy. This is in line with what women have always told us, that they want to know about the risks associated with prenatal alcohol exposure.

The recent period of growth in guidance, research and publications around FASD has called for the development of further resources and campaigns which look to support the maternity team to have better discussions around alcohol in pregnancy.

The Alcohol & Pregnancy toolkit

The National Organisation for FASD’s new Alcohol and Pregnancy Toolkit will be launched on 21st June 2023 at the National Liberal Club in London. Tickets are free but limited and can be reserved here : Attendees will have the opportunity to learn more about the recent updates and how the new Alcohol and Pregnancy Toolkit will support them to meet the new standards. There is also the opportunity to ask questions to a panel of experts on PAE and FASD. Attendees will receive a certificate of attendance which can be used to support continuing professional development as part of the NMC’s revalidation requirements.

The Alcohol and Pregnancy Toolkit is a suite of new resources and a new free e-course specifically designed to help Maternity Services and Commissioners to improve quality of care in line with NICE Quality Standard 204 and latest governmental guidance. The Alcohol and Pregnancy toolkit has been extensively reviewed by the National FASD Experts Committee as well as our Special Advisory Midwives Committee. The toolkit aims to support and empower Maternity Teams to have conversations around alcohol in pregnancy. It ensures that they have the latest information and policy on alcohol in pregnancy and FASD through resources such as the CPD accredited e-course, written leaflets, practitioner fact cards and tabletop guides. We hope that Midwives and the whole Maternity Team can feel confident to share their knowledge with pregnant women to ensure that they are made aware of the risks associated with drinking alcohol in pregnancy. We want to enable midwives to accurately record alcohol intake to aid further support and future diagnosis of FASD where needed.

To learn more about FASD please visit: Home – National FASD. Information about how to access the toolkit will be available after the launch. The free e-course will soon be available on These materials were made possible due to support from Diageo GB.


Chief Medical Officers’ (2016) Low risk drinking guidelines. Available at: UK Chief Medical Officers’ Low Risk Drinking Guidelines (

Department of Health and Social Care (2021) Fetal alcohol spectrum disorder: health needs assessment. Available at: Fetal alcohol spectrum disorder: health needs assessment – GOV.UK (

McCarthy, R., Mukherjee, R. A. S., Fleming, K. M., Green, J., Clayton-Smith, J., Price, A. D., Allely, C. S., & Cook, P. A. (2021). Prevalence of fetal alcohol spectrum disorder in Greater Manchester, UK: An active case ascertainment study. Alcoholism, clinical and experimental research45(11), 2271–2281.

National Institute of Health and Care Excellence (2022) Fetal alcohol spectrum disorder (Standard no. 204). Available at: Overview | Fetal alcohol spectrum disorder | Quality standards | NICE

NHS Digital (2019) Health Survey for England 2019 Adults’ health-related behaviours –Adult health related behaviours (

O’Brien, N (2022) Correspondence to Sandra Butcher, Chief Executive, National Organisation, from Neil O’Brien MP, Parliamentary Under Secretary of State for Primary Care and Public Health, 8 December 2022


PHE (2018) Health matters: reproductive health and pregnancy planning –Health matters: reproductive health and pregnancy planning – GOV.UK (

Popova, S., Lange, S., Probst, C., Gmel, G., & Rehm, J. (2017). Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis. The Lancet. Global health5(3), e290–e299.

Popova, S., Lange, S., Shield, K., Mihic, A., Chudley, A. E., Mukherjee, R. A., … & Rehm, J. (2016). Comorbidity of fetal alcohol spectrum disorder: a systematic review and meta-analysis. The Lancet387(10022), 978-987.

Public Health England (2020) Maternity high impact area: Reducing the incidence of harms caused by alcohol in pregnancy. Available at: Maternity high impact area 4: Reducing the incidence of harms caused by alcohol in pregnancy (

Schölin, L., Watson, J., Dyson, J., & Smith, L. A. (2021). Midwives’ views on alcohol guidelines: A qualitative study of barriers and facilitators to implementation in UK antenatal care. Sexual & Reproductive Healthcare29, 100628.

Scottish Intercollegiate Guidelines Network (SIGN)(2019) Children and young people exposed prenatally to alcohol: a national clinical guideline. Available at:

Smith, L. A., Dyson, J., Watson, J., & Schölin, L. (2021). Barriers and enablers of implementation of alcohol guidelines with pregnant women: a cross-sectional survey among UK midwives. BMC pregnancy and childbirth21, 1-9.

(1) Joanna Buckard

(2) Katie Liddle

May 2023

[1] Joanna Buckard is the Director of Innovation at National FASD and has nearly 2 decades of experience in multiagency FASD training including specialist training for midwives. She sits on the National FASD Experts Committee and is Project lead on the Alcohol and Pregnancy Toolkit. She has previously conducted research into the lived experience of adults with FASD in the UK and How FASD is managed in the UK criminal justice system.

(2) Katie Liddle is a Research and Project Officer at National FASD and a qualified Midwife.