Provision of information by midwives for pregnant women in England on guidance on foods/drinks to avoid or limit

doi:10.21203/rs.3.rs-1985550/v1

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Provision of information by midwives for pregnant women in England on guidance on foods/drinks to avoid or limit

https://doi.org/10.21203/rs.3.rs-1985550/v1

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published 08 Mar, 2023

Read the published version in BMC Pregnancy and Childbirth →

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Background

The NHS website gives guidance for pregnant women in England on foods/drinks to avoid or limit because of microbiological, toxicological or teratogenic hazards. These include, for example, some types of soft cheeses, fish/seafood and meat products. This website and midwives are trusted sources of information for pregnant women, but the ways in which midwives can be supported to provide clear and accurate information are unknown.

Aims

The aims were to: (1) determine midwives’ accuracy of recall of information and confidence in delivering the guidance to women; (2) identify barriers to provision; (3) identify the ways in which midwives provide this information to women.

Methods

Registered Midwives practicing in England completed an online questionnaire. Questions included those on what information they provided and their confidence in delivering it, the ways they provided information on foods to avoid/limit, and what resources they used. Ethics approval was given by the University of Bristol.

Results

>10% of midwives (n = 122) were ‘Not at all confident’ in providing advice about seven items, including game meat/gamebirds (38% and 39%, respectively), herbal teas (13%) and cured meats (12%). Only 32% correctly recalled overall advice on eating fish, and only 38% the advice on tinned tuna. The main barriers to provision were lack of time in appointments and lack of training. The most usual methods of disseminating information were verbal (79%) and signposting to websites (55%).

Conclusion

Midwives were in general knowledgeable about foods and drinks to avoid/limit during pregnancy, but there were some foods for which they were unconfident, and some for which recall was mistaken. Delivery of guidance by midwives on foods to avoid or limit needs to be supported by appropriate training and access to resources. Further research on barriers to the delivery and implementation of the NHS guidance is needed.

pregnancy

diet

nutrition guidance

public health nutrition

midwife

The guidance given to pregnant women in England is to follow a healthy diet broadly similar to that advised for the general population [2]. There is additional guidance on several items of foods and drinks that pregnant women are advised to either limit or avoid consumption altogether [3–10]. This guidance is based on several factors as follows. (1) Exposure to toxic metals and pollutants such as mercury, lead, dioxins and polychlorinated biphenyls (e.g. from some types of fish, game meat/gamebirds) is associated with a risk of adverse developmental effects including neurodevelopmental disorders [11–14]. (2) Microbiological hazards such as listeria, toxoplasmosis and salmonella (e.g. from unpasteurised milk, some types of soft cheese, uncooked cured meats) can lead to miscarriage, premature birth and stillbirth [15, 16]. (3) Excess provision of vitamin A (e.g. in liver and liver products) can cause teratogenesis [17]. (4) Pharmacological actions or interactions with drugs can be caused by some types of herbal teas, including fennel, ginger, chamomile and peppermint [18]. Non-compliance with guidance on foods and drinks to avoid or limit in pregnancy can have serious consequences. In 2019, for example, pregnancy-associated cases of listeria accounted for 18% of all cases and one-third of these cases resulted in stillbirth or miscarriage in England and Wales [19].

The main summary of guidance on foods and drinks to avoid or limit in pregnancy is provided an NHS website page for England [3], but information is also available through a range of leaflets and apps, and on other websites hosted by charities and commercial organisations. Provision of this information in a way that is readily accessible and easily understood by women is essential. Midwives are highly trusted sources of information for women [20] and it is crucial that they are enabled to provide information on the guidance confidently, effectively and accurately, whether this is directly or by signposting to other sources of information. The aims of this study were to determine: (1) the accuracy of midwives’ recall of information and how confident they are in their ability to deliver the guidance to women; (2) the barriers to optimal provision of information; (3) the ways in which midwives provide information on the guidance on foods and drinks to avoid or limit to women and what resources they use. This was intended to inform the possible need for additional training and resources on the guidance.

The study is part of a larger mixed methods study on dietary exposure to toxic metals in pregnancy (Pregnancy, Environment And nutRition (PEAR) Study) [21]. Midwives practising in England and delivering antenatal care in the previous 2 years were invited to complete a custom-designed online questionnaire hosted on Jisc Online Surveys [22]. Ethics approval was given by the University of Bristol Health Sciences Research Ethics Committee (reference 106742, 21 April 2021). The primary purpose of the study was to investigate guidance on foods that contribute to exposure to toxic metals (mercury and lead) in pregnancy within the context of foods and drinks to avoid or limit more generally (see Supplementary Table 1 for a complete list of foods, drinks and supplements included in NHS guidance for England).

The initial version of the questionnaire was tested with midwives in an adapted ‘Think Aloud’ exercise and modified according to their feedback [23]. Participants (n = 7) were emailed a link to access the electronic questionnaire and answered each question in the presence of a researcher (LB). ‘Think Aloud’ discussions were conducted remotely via video or telephone call and were recorded using an encrypted digital audio-recorder. Participants were asked to ‘Think Aloud’ as they accessed and filled in the questionnaire, vocalising their thoughts about the questions, covering, for example, any comprehension issues, the acceptability of available answers and technical problems including skip rules and the order of questions. Three ‘practice questions’ were provided at the beginning of the questionnaire to ensure the participant understood what the exercise involved. Questions and queries from the participant were addressed by the researcher, who made brief field notes during the exercise and remained silent other than a polite reminder to the participant to ‘keep thinking aloud’ if they fell silent. When the participant had completed the questionnaire, the researcher used notes made during the exercise to probe any area where the participant seemed uncertain. Development of the questionnaire was iterative, with alterations being made in response to the comments of up to five participants at a time, until data saturation was reached and no new issues were reported.

The finalised questionnaire was open from April 2021 to December 2021. Participants were recruited primarily through publicity on the Royal College of Midwives website, professional networks, snowballing, Twitter adverts, and with paid advertising boosts on a study Facebook page linked to the study website (with direct access to the questionnaire from the study website [21]. Informed consent to participate was assured by completion of the questionnaire. With the exception of the screening questions to determine eligibility, no questions were compulsory to maximise the completion rate. Participants were able to re-access their partially completed questionnaire so that they did not have to complete it in one session. Questions included those in the following categories.

(1) Screening questions (confirmation of being a Registered Midwife (RM) practising in England and regularly providing antenatal care within the last 2 years)

(2) Demographics (e.g. how many years worked as a RM, NHS AfC band, qualifications, age, location, ethnicity, etc.)

(3) Confidence in ability to provide information about the guidance to women (e.g. on soft cheeses, unpasteurised milk, etc.) and recall of guidance on specific foods (types of fish, gamebirds/game meat)

(4) Barriers to ability to provide provision of information on guidance to pregnant women

(5) Methods of provision of information about the guidance to women (e.g. verbal, leaflet, signposting to NHS website, other websites or apps)

The data were analysed with IBM SPSS Statistics version 26 using summary and descriptive statistics.

The questionnaire information page was accessed by 1421 respondents. 1219 did not progress beyond the information page. 11 were screened out as ineligible. The survey was completed by 122 participants, giving a completion rate of 122/202 (60%) for those who progressed beyond the information page. The demographics of the participants are shown in Table 1.

Table 1

Demographics of midwives completing online questionnaire
Demographic	n (%)
Worked as an RM (years)
0–10	64 (52%)
>10–20	28 (23%)
>20	30 (25%)
Current NHS AfC band
Band 5 or 6	96 (79%)
Band 7 or 8	24 (20%)
Hours of work^c
Full time (37.5 hours/week)	57 (47%)
Part time (< 37.5 hours per week)	64 (53%)
Qualifications^a
Degree/MSc in Midwifery	103 (84%)
Diploma/Advance Diploma in Midwifery	15 (12%)
Certificate in Midwifery	12 (10%)
Other	6 (5%)
Main antenatal work setting
Community setting	69 (57%)
Hospital	25 (21%)
Delivery suite	9 (7%)
Other	19 (16%)
Run antenatal classes in last year^c
Yes	12 (19%)
No	98 (81%)
Additional training in nutrition/diet^c
Yes	13 (11%)
No	108 (89%)
Age
>50	30 (25%)
>30–49	62 (51%)
<30	30 (25%)
Location
North East/North West/Yorks and Humber	19 (16%)
East Midlands/West Midlands/East of England	5 (4%)
Central or Greater London/South East/South West	98 (80%)
Ethnicity^d
White	113 (95%)
Other	6 (5%)
Special diet^a,b
Yes	45 (37%)
No	77 (63%)
^aParticipants could choose more than one category.
^bVegan/vegetarian/flexitarian 25 (56%); Low carb/gluten or wheat free/Paleo or Atkins 9 (20%); Other (dairy free, FODMAP, low calorie) 11 (24%).
n = 122 except for ^cn=121, ^dn=119.

Data not shown due to participant number ≤ 5 for some categories.
RM, Registered Midwife.

Most midwives were ‘Confident’ or ‘Very confident’ in their ability to deliver the correct advice on specific foods and drinks to avoid/limit during a routine appointment (> 80% ‘Confident’ or ‘Very confident’ for eggs, soft cheese, liver/liver products, pate, unpasteurised milk, caffeinated drinks, alcohol) but there were some items for which this was not the case: >10% were ‘Not at all confident’ for gamebirds (39%), game meat (38%), omega-3 supplements (25%), herbal teas (13%), cured meats (12%), white fish (12%), peanuts (11%) and shellfish (11%) (Table 2).

Table 2

Midwives’ confidence in providing advice on foods and drinks to avoid or limit in a routine appointment (n = maximum 122)
	Don’t know/Not at all confident/ Fairly confident^a	Confident/ Very confident^a
Foods
Dairy products
Soft cheese^{b k}	12 (10%)	109 (90%)
Unpasteurised (raw) milk	11 (9%)	111 (92%)
Meat and meat products
Pâté (meat and vegetarian)	14 (11%)	108 (89%)
Liver and liver products	11 (9%)	111 (91%)
Cured meats^c	42 (34%)	80 (66%)
Gamebirds^d	81 (66%)	41 (34%)
Game meat^{e k}	80 (66%)	41 (34%)
Seafood
White fish^f	24 (20%)	98 (80%)
Tinned tuna	20 (16%)	102 (84%)
Oily fish^g	19 (14%)	103 (86%)
Fresh tuna	30 (25%)	92 (75%)
Shark/marlin/swordfish	21 (17%)	101 (83%)
Sushi ^k	35 (29%)	86 (70%)
Shellfish ^k	33 (27%)	88 (72%)
Peanuts ^k	32 (26%)	89 (74%)
Eggs	11 (9%)	111 (91%)
Drinks
Caffeinated drinks
Tea/coffee	18 (15%)	104 (85%)
Soft drinks	19 (16%)	103 (84%)
Energy drinks^{h k}	19 (16%)	102 (84%)
Herbal teasⁱ	44 (36%)	77 (64%)
Alcohol^j	6 (5%)	116 (95%)
Supplements
Healthy Start vitamins ^k	16 (13%)	105 (86%)
Pregnancy multivitamins	6 (5%)	116 (95%)
Standard multivitamins	22 (18%)	100 (83%)
Folic acid (folate) supplements	7 (6%)	115 (94%)
Omega-3 supplements ^k	57 (47%)	64 (53%)
Vitamin D	10 (8%)	112 (92%)
Iron	7 (6%)	115 (94%)
Foods, drinks and supplements included are those listed on NHS guidance for England on avoiding or limiting during pregnancy [3–10].
^aColumns elided due to participant number ≤ 5 for some items. Values for ‘Don’t know’ not shown due to participant numbers ≤ 5 for some items.
Examples include: ^bBrie, camembert, Danish blue, soft goat’s cheese; ^cSalami, prosciutto, pepperoni, chorizo; ^dGrouse, goose, pheasant, partridge, pigeon; ^eVenison/deer, hare, rabbit, wild boar; ^fHaddock, cod, pollock, tilapia, including breaded fish and fish fingers; ^gSalmon, trout, mackerel, herring; ^hRed Bull, Monster; ⁱGinger, raspberry, mint; ^jWine, beer, spirits, cider, alcopops, cocktails.
n = 122 or ^k121

With regard to recall of guidance on some specific items, however, 68% were not able to correctly recall the guidance for overall fish consumption, 12% for white fish, 47% for oily fish, 62% for tinned tuna (54% incorrectly thought that the advice was to eat up to two medium sized cans per week), 57% for fresh tuna, and 21% for shark/marlin/swordfish. Sixty-nine percent did not correctly recall the guidance on gamebirds and 74% on game meat.

Only 14 (12%) of the participants felt they could always deliver the service they would ideally like in giving information on diet to pregnant women and 23 (19%) felt that they were never able to do this. Common reasons for prevention of delivery of an ideal service included lack of time in appointments (n = 81 (66%)), lack of training (n = 64 (58%)) and lack of suitable resources to be passed on (n = 51 (42%)).

The most prevalent method of midwives providing information on the guidance to women on foods and drinks to avoid or limit was verbal, followed by signposting to websites, primarily the NHS website, and to apps, primarily NHS Trust-specific apps (Table 3).

Table 3

Midwives’ methods of provision of information
Methods	Information on general healthy eating	Information on foods/drinks to avoid or limit	Resources for information on foods/drinks to limit or avoid^a
Verbal	109 (89%)	96 (79%)
Information about websites	66 (54%)	67 (55%)	NHS Choices Website	66 (99%)
			Start4Life	22 (33%)
			Online pregnancy book	17 (25%)
			Tommy’s	16 (23%)
			BBC Website/Mumsnet/Other	13 (19%)
Maternity handheld records	59 (48%)	54 (44%)	-	-
Information about apps	40 (33%)	29 (24%)	Trust-specific app	23 (79%)
			Pregnancy+/Emma’s Diary/Baby 2 Body/Oviva/Baby Buddy/Other	12 (41%)
Leaflet	28 (23%)	23 (19%)	NHS leaflets	18 (78%)
			Local hospital trust	13 (57%)
			British Dietetic Association/Royal College of Midwives/Royal College of Obstetricians and Gynaecologists	7 (4%)
Participants were able to choose more than one category.
n = maximum 122.
^aSome categories have been elided or not shown because of low values.

In general midwives were knowledgeable about national guidance on foods and drinks to avoid or limit, and confident in their ability to do so. However, there were some items for which they were not confident and some for which their recall of the guidance was incorrect. Since the most usual method of delivery of information was verbal it is essential that midwives are able to deliver the information confident and accurately. Many reported that they were unable to deliver the level of service that would like on information on diet in pregnancy, primarily due to lack of time in appointments and lack of training.

Studies on nutrition guidance in pregnancy have generally focused on healthy eating guidance and diet quality [24, 25], or on a particular age group [26] or food item (e.g. fish [27]), with the few studies on specific foods to avoid or limit mainly focussed only on listeria [28, 29]. Both women’s knowledge of guidance and adhering to it appear to be limited: a study of pregnant and recently pregnant women in Australia found that women’s knowledge of foods to avoid was poor (93% incorrectly identified at least one unsafe food as safe to eat)[30] and in Canada only 53% of a group of pregnant women made dietary changes to follow food safety recommendations[31]. We have previously reported that adherence to the guidance by women resident in England during pregnancy is generally good, but there are some items for which it is not: herbal tea, gamebirds and game meat, cured meats, soft cheese and standard multivitamins [20]. However, there are no previous reports to our knowledge on the role of midwives or other healthcare professionals in advising women and supporting their choices on foods/drinks to avoid or limit in pregnant. For several of these items - herbal tea, gamebirds/game meat, and cured meat – a large proportion of midwives in the present study were ‘Not at all confident’ in delivering information, suggesting that is a need for further training for midwives to support their knowledge.

For the items for which midwives were asked to recall the guidance, knowledge around frequently consumed types of fish, such as tinned tuna, is of particular concern. 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. This may be caused by confusion with the population level message to eat at least two portions of fish per week (including in pregnancy)[32], although this guidance is not explicitly stated on the guidance for pregnancy. There was similar uncertainty about the number of portions of oily fish advised (correct advice is to eat at least one but no more than two portions a week). Lack of knowledge on the restrictions advised on herbal tea (no more than four cups per day) is particularly concerning, especially as there is some evidence that women swap to herbal tea as a result of cutting back on caffeinated drinks [20] and it may be seen as a ‘healthy choice’. Some of the advice on the NHS website, particularly on soft cheese, cured meats and fish, is complex and may be difficult to retain.

The strengths of this study are twofold. First, the delivery of the guidance by midwives and their confidence in providing the guidance to women has not been studied before in England in any way to our knowledge. It is essential that use by healthcare providers is considered in the design of public health messages, and they must be supported with additional resources and training where needed. Second, the anonymity of the online survey method may have allowed 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 one-to-one setting.

There are several limitations to this study. First, we only included 122 respondents, although this was sufficient to indicate some areas of uncertainty in their knowledge and the need for further appointment time and specialist training. However, it prevented 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, many appointments with women were conducted online during this time and this may have affected the clarity of communication between midwives and pregnant women compared with usual face-to-face appointments.

In conclusion, generally midwives were knowledgeable about foods and drinks to avoid or limit in pregnancy, but there were some items for which they were unconfident and sometimes mistaken. It is important to ensure that midwives are able to access appropriate training and resources on the guidance on foods and drinks to avoid or limit. It is also important that the NHS website is completely clear and consistent in its messages, particularly on the total number of portions of fish and portions of oily fish per week advised per week. Further research is needed on the barriers to the optimal implementation of the guidance by pregnant women.

Data access statement:Underlying data are subject to an embargo until the end of the study funding in 2025. The data will then be made available to bona fide researchers on application from data.bris.ac.uk/data.

Conflicts of interest: The authors have no conflicts of interest to declare.

Ethics approval: Ethics approval was given by the University of Bristol Health Sciences Research Ethics Committee (reference 106742, 21 April 2021). All methods were carried out in accordance with relevant guidelines and regulations. Informed consent to participate was assured by completion of the questionnaire.

Consent to publication: Not applicable.

Funding: This work was funded by an MRC Career Development Award to CMT (grant number MR/T010010/1).

Acknowledgements: We are grateful to all the respondents who completed the questionnaire and to the Royal College of Midwives for publicising the study. These data were presented in part at the Royal College of Midwives Education and Research Conference 2022 [1].

Author contributions: The study was conceived by CMT and designed by CMT and LB with critical inputs from JI. LB carried out the research work and analysed the results with CMT. LB and CMT wrote the manuscript with critical input from JI and RT. All authors have approved the final version of the paper.

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No competing interests reported.

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Provision of information by midwives for pregnant women in England on guidance on foods/drinks to avoid or limit

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