Background: Alcohol consumption during pregnancy is a major public health concern and the leading cause of foetal alcohol spectrum disorders (FASD), one of the most common preventable congenital conditions in Europe. Despite clear recommendations for abstinence, uncertainty persists among both pregnant women and healthcare professionals about how to address the issue.

Objective: This study explores expert perspectives on alcohol use during pregnancy and examines counselling practices and challenges in antenatal care.

Participants and settings: A qualitative study was conducted using structured interviews with 14 midwives in Austria and four addiction medicine experts between May and July 2025.

Methods: Interviews were transcribed, pseudonymised and analysed inductively following Mayring's qualitative content analysis to develop higher-level categories.

Findings: Alcohol consumption affects women across all social groups and is highly stigmatised during pregnancy. Shame, fear of judgement and the social normalisation of alcohol hinder open communication. Midwives generally adopt a zero-tolerance approach but report uncertainty in managing psychosocial aspects and suspect underreporting. Counselling mainly relies on verbal history-taking and documentation in the parent-child-pass, while standardised screening tools are rarely used. A strong need for interprofessional collaboration, clear referral pathways and practical support services was identified.

Conclusion: Alcohol use during pregnancy is complex and highly stigmatised, posing challenges for counselling and prevention. Midwives play a central role but require stronger structural support, training and networks. Effective prevention depends on early, low-threshold, non-judgemental education, consistent screening and improved public awareness of prenatal alcohol risks.