Provision of information by midwives for pregnant women in England on guidance on foods/drinks to avoid or limit | BMC Pregnancy and Childbirth

In general, midwives were not confident in their ability to provide guidance to women on foods and drinks to avoid or limit, with > 90% reporting that were Confident/Very confident for only four items: liver/liver products, unpasteurised milk, alcohol and eggs. There were some items for which they were particularly unconfident (< 65% Confident/Very confident for herbal tea, omega-3 supplements, game birds and game meat). Although most midwives reported being Confident/Very confident in their knowledge of the guidance on fish (> 70% for all items related to fish), their recall for most of these items was usually inaccurate (for example, 38% correct recall for guidance on tinned tuna, 53% for oily fish). Similarly for gamebirds and game meat, recall was correct in only 31% and 26%, respectively. Since the most usual method of delivery of information was verbal it is essential that midwives are able to recall the information confidently and accurately, and it suggests that there is a need for further training for midwives to support their knowledge. Nearly 20% of midwives reported that they were never able to deliver the ‘level of service that they would like to’ on information on diet in pregnancy, and this was primarily due to lack of time in appointments and lack of suitable and accessible training.

Lack of confidence in knowledge on the restriction advised on herbal tea (no more than four cups per day [3]) is particularly concerning. Herbal teas commonly used by women during pregnancy include ginger, raspberry, cranberry, echinacea, peppermint and chamomile [38], and they have traditionally been used to treat a range of conditions including nausea, anaemia, constipation, heartburn and sleeping problems, and used in preparation for labour. Herbal teas carry a risk of herb–drug interactions: for example, tannin-containing herbs, such as raspberry leaf, can interfere with iron absorption; ginger and chamomile enhance the effect of CNS depressants so are not advised in patients taking drugs such as clonazepam; St John’s wort interacts with several drugs (for example anticoagulants, anticonvulsants, immunosuppressants). Other herbs contra-indicated in pregnancy include cohosh, Ginko bilbao, St John’s wort and others, because they are abortifacients, cathartic laxatives or emmenagogues, or have hormonal effects or affect uterine contractions [38]. There is recent evidence that women simultaneously cut back on caffeinated drinks as advised but increase herbal tea consumption [33], possibly as a result of herbal teas being seen as a ‘healthy choice’ [39].

Lead-shot game meat and gamebirds are likely to be consumed by few women, but amongst that those that do consume them, it is likely that some women will be frequent consumers [40] (for example, women who have a personal or professional association with shooting activities). Midwives need to be aware of both this group of women and the guidance on lead-shot game meat/gamebirds in order to deliver information to this group of women, with aim of preventing adverse neurodevelopmental outcomes in the fetus [10]. The identification of meat as not being lead shot, perhaps through a voluntary labelling scheme, would be helpful in this regard.

For the items for which midwives were asked to recall the guidance, poor knowledge around frequently consumed types of fish, such as tinned tuna, was striking. Many respondents recalled the advice as being up to two medium-sized cans of tuna per week, when it is actually up to four cans per week [3]. This may be caused by confusion with the population level message to eat at least two portions of fish per week (including during pregnancy) [2, 31]. There was similar uncertainty about the number of portions of oily fish advised (the correct advice is to eat at least one but no more than two portions a week [3]).

Healthcare professionals, including midwives, have been identified in other studies as being trusted providers of this information by women [25, 29], and they have a central role in health promotion facilitated by regular contact with women throughout their pregnancy [41]. In Australia, it has been observed that most interactions between midwives and women are medically directed [42], and this is likely to be similar in England, limiting opportunities for discussion of diet-related information. In a narrative review of the role of midwives in the promotion of healthy lifestyle in pregnancy, Bahri Khomami et al. [22] identified several barriers to optimal delivery of information by midwives, including lack of content in undergraduate midwifery curricula to provide the knowledge, skills and confidence needed to assess and support healthy lifestyles, and lack of training in the workplace. A systemic review specifically of nutrition advice in pregnancy reported similar barriers in healthcare professionals in many countries including the UK, Europe, Australia, New Zealand, Canada and the United States of America [43]. For midwives in the present study the barriers to delivering guidance on foods/drinks to avoid or limit also included lack of training and lack of access to suitable resources; in addition the participants highlighted the lack of time in appointments, which were largely focused on clinical aspects. For women, barriers to following advice on foods/drinks to avoid or limit may include lack of awareness, but also having had no prior illness from consuming those foods, preferences for those foods, perception of their health benefits, and convenience [44]. As stated by Bahri Khomami et al. [22], it is critical that barriers to the provision of best practice by midwives at all levels (individual, system and policy) are addressed, including provision of undergraduate and postgraduate training, and enabling health systems to include adequate appointment time to enable provision of information for women within standard care. Co-designed training materials and resources for midwives could encompass, for example, annual professional training courses, intermittent nutrition specialism courses, and online resources.

Where women lack knowledge on guidance on foods and drinks to avoid and limit, they will continue to consume foods and drinks that could put them and their fetus at risk of adverse pregnancy outcomes (in Australia, for example, 83% of a sample of 223 women incorrectly identified at least one unsafe food as being safe to eat [27]; similarly, Canadian women’s knowledge of foods that are high-risk for listeria was poor [25]). This strengthens the case for the role of healthcare providers, including midwives, in providing or signposting information. However, even knowledge of the guidance does not always result in women following it: a study of recently postpartum women in Ireland found that even though more than 80% of the sample (n = 271) knew that they should avoid foods at high risk of transmitting listeria during their pregnancy, 55% reported consuming them during their pregnancy [26]. Although women are known to have a high rate of compliance with guidance on health-related behaviours such as cigarette smoking and alcohol consumption in pregnancy, changes related to heathy eating such as increases in fruit and vegetable intake are harder to achieve [45], with little change in dietary patterns from before to during pregnancy [46]. However, for foods and drinks to avoid or limit where is a clear association between consumption and a possible hazard, risk aversion emerges as an additional factor that may be powerful in altering consumption patterns: for example, risk aversion to mercury underpinned other themes that together shaped perception of fish consumption during pregnancy in a qualitative study in Australia [24]. This suggests that both the content and delivery of information may need to be designed in a different way from healthy eating information in order to have an impact.

The NHS website was also identified as a key source of information that midwives signposted women to. Midwives should be enabled to be familiar with the information there and have an accurate recall of it, and the website should provide clear, up-to-date evidence-based guidance. The guidance on fish, for example, does not include the overarching message for pregnant women to eat at least two portions of fish a week as recommended by SACN [31], and this may contribute to fish intakes in pregnancy being below those recommended [3, 47]. Updates (for example, new guidance on cooking smoked fish in response to a listeria outbreak linked to smoked fish in 2022) should be well publicised to both women and midwives. Advice on omega-3 supplements is currently displayed in on a page concerned with supplements rather than the main page [5]: this could be made more readily accessible.

The strengths of this study are twofold. First, we used the Think Aloud process to validate the questionnaire with participants who fulfilled the eligibility criteria for the finalised questionnaire. Second, reporting bias was minimised as the anonymity of the online survey method enabled midwives to be honest in stating whether they felt unconfident in their knowledge in a way that they might not have been in a group or even a one-to-one setting.

There are several limitations to this study. First, we only included 122 respondents, although this was sufficient to indicate areas of uncertainty in their knowledge and the need for further in time appointments and specialist training. However, it prevented high powered analysis of the associations between demographic characteristics of the midwives and their responses. Our survey was open during Covid restrictions, which had a great impact on the daily workload of midwives, and this may have limited the response rate. Second, the study was not representative of the population of midwives in England, particularly in geographical location and ethnicity, which limits generalisability. Third, we were unable to include questions about recall for all foods/drinks for which guidance is to avoid or limit, and this will important to include in future larger scale studies. Finally, many midwife-led appointments with women were conducted online during this time and this may have affected time available and the clarity of communication between midwives and pregnant women compared with usual face-to-face appointments.