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We invite comments on the proposed minimum price of 50 pence per unit which is set out in the draft Scottish Statutory Instrument at Annex A.

We invite comments on the proposed minimum price of 50 pence per unit which is set out in the draft Scottish Statutory Instrument at Annex A .
The Royal College of Midwives (RCM) is the trade union and professional organisation that represents the vast majority of practising midwives in the UK. It is the only such organisation run by midwives for midwives. The RCM is the voice of midwifery, providing excellence in representation, professional leadership, education and influence for and on behalf of midwives. We actively support and campaign for improvements to maternity services and provide professional leadership for one of the most established clinical disciplines. The RCM welcomes the opportunity to respond to this consultation and our answers to the consultation question is set out below. We support the general principles of the Minimum Unit Pricing of Alcohol policy and believe that it will make a contribution to improve and protect the health and wellbeing of the population of Scotland. However we do not believe that a minimum pricing strategy alone will be sufficient to address what is a major public health problem. We would urge the Scottish Government to look at how minimum pricing can be made more effective by other, simultaneous initiatives. According to Health First, an evidence-based alcohol strategy for the UK which the RCM supports, we must tackle the primary drivers of alcohol consumption if the vision of a safer, healthier and happier world where the harm caused by alcohol is minimised. The report states that there is clear evidence that the most effective way to reduce this harm is to reduce not only the affordability but also the availability and attractiveness of alcohol products. Targeting support to vulnerable individuals who consume large amounts of alcohol needs to address the underlying causes of their vulnerability, for example housing, social support, financial pressures, employment and mental health. Strong referral pathways need to be in place to ensure that wherever vulnerable alcohol abusers seek help in Scotland, professionals and volunteers can address these underlying issues. At the moment alcohol is freely available for sale and heavily marketed and advertised. Alcohol producers and public health professional and charity organisations will have competing interests but small advances have been made in recent years with labelling and restrictions on price promotions. However, the harms from alcohol continue and it is therefore up to government to put measures in place, either through legislation or public health policy to minimise harm. In addition to minimum pricing, measures could include reducing the availability of alcohol, reducing the amount of advertising and targeted advertising, more strident information about alcohol harms on packaging and plain packaging (as has happened with cigarettes) and the reduction of allowed blood alcohol concentration in drivers. We would encourage the Scottish Government to think big and take a zero-tolerance approach to alcohol harm. There must be a well-funded and accessible specialist alcohol service across Scotland so that appropriate assessment and treatment can take place. In addition all health professionals should be able to give brief advice on alcohol consumption, be able to refer appropriately when required. There must be a robust a referral pathway that is known to and understood by those who work across health and social care, local authorities and charities. Measures such as this are even more important now that we have more evidence on the harm from alcohol to women and babies, and clear the advice from the four UK Chief Medical Officers in regards to minimising drinking. The RCM endorses this advice: “If you are pregnant or think you could become pregnant, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum. Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk.” It continues: “The risk of harm to the baby is likely to be low if you have drunk only small amounts of alcohol before you knew you were pregnant or during pregnancy. If you find out you are pregnant after you have drunk alcohol during early pregnancy, you should avoid further drinking. You should be aware that it is unlikely in most cases that your baby has been affected. If you are worried about alcohol use during pregnancy do talk to your doctor or midwife.” This advice is in keeping with the aims of minimum unit pricing, which seeks to reduce heavy drinking by increasing the price of high-strength alcohol and making frequent drinking less attractive. However, it is also important to note that midwives cannot and should not be cast as social police in enforcing women’s behaviour and this is not the message of the Chief Medical Officer, though this is often misinterpreted. ‘Policing’ does not encourage women to practice self-care and can make engaging with services less likely. It also will do nothing to help women with co-morbidity issues like domestic abuse or mental health, where early engagement is absolutely critical to improving clinical outcomes. Rather, the midwife’s skill is in conveying relevant, evidence based information, in a format that will be understood by the women, while offering support to those who consume alcohol when pregnant. This is especially important as not all pregnant women will be drinking the alcohol that is captured by minimum pricing. Women who drink in pregnancy are not a homogenous group and so our response to this concern must not be a one-size fits all approach. It is a myth that Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Spectrum Disorders (FASD) happens to ‘one’ kind of family. Alcohol also creates indirect harms to women and their unborn children through its relationship to violence against women and girls (VAWG). Research shows that 30 per cent of cases of domestic abuse begin in pregnancy and 40-60 per cent of women experience domestic abuse while they are pregnant. In England and Wales 36 per cent of domestic violence incidents are committed by people who have been drinking. We note the Consultation document lists many of the links between crime and alcohol use but we would like the Scottish Government to see alcohol policy as a specific lever to reduce VAWG. A 2016 study found that overall, domestic violence doubled the risk of preterm birth and low birth weight. This risk was increased further for women who experienced two or more types of domestic violence during their pregnancy. Pre-term birth is a significant contributor to neonatal death, and poor long term health outcomes. The risk continues into the postnatal period where research has found that ‘after the birth of their first child 23 per cent of parents continued to drink as much as before their baby was born and 17 per cent increased the amount they consumed. Overall around three in ten parents drank more than the recommended units per week. Parents may be putting their new born babies at risk because they are under the influence of alcohol. In summary, the RCM, while supporting minimum alcohol pricing, believes that the Scottish Government must take a whole-system approach to reducing the harms of alcohol to mothers and babies. This must take into account the ‘trusted’ role midwives have in public health in the relationships they build with women, their ability to refer to other services, the relationship between vulnerability, co-morbidities and alcohol use, and the relationship between alcohol and VAWG. We urge the Scottish Government to continue to develop policy within a range of areas so that minimum alcohol pricing will be supported by other evidence-based initiatives to reduce alcohol harm. The Royal College of Midwives January 2018 References: Health First: an evidence-based alcohol strategy for the UK (2013). University of Stirling, https://www.stir.ac.uk/media/schools/management/documents/Alcoholstrategy-updated.pdf UK Chief Medical Officers’ Low Risk Drinking Guidelines (2016). Department of Health (UK), Welsh Government, Department of Health (Northern Ireland), Scottish Government. http://www.gov.scot/Resource/0050/00504757.pdf On domestic violence, alcohol and maternal and neonatal outcomes: Lewis, G (ed) 2007. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer - 2003-2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH. http://www.publichealth.hscni.net/sites/default/files/Saving%20Mothers%27%20Lives%202003-05%20.pdf ONS (2015). Violent Crime and Sexual Offences - Alcohol-Related Violence. https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/compendium/focusonviolentcrimeandsexualoffences/2015-02-2/chapter5violentcrimeandsexualoffencesalcoholrelatedviolence Donvan et.al. (2016). Intimate partner violence during pregnancy and the risk for adverse infant outcomes: a systematic review and meta-analysis. BJOG, 123, 8. http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.13928/full WHO (2015). WHO recommendations on interventions to improve preterm birth outcomes. http://apps.who.int/iris/bitstream/10665/183037/1/9789241508988_eng.pdf 4Children (2012) Over the Limit: the truth about families and alcohol. http://www.fairplayforchildren.org/pdf/1351833639.pdf

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The Royal College of Midwives, Scotland