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Update from the CDC

Addressing Alcohol Use in Pregnancy

Mitchell, Ann M. PhD, RN, AHN-BC, FIAAN, FAAN; Porter, Rebecca R. MS, LPC; Pierce-Bulger, Marilyn MN, FNP-BC, CNM; McKnight-Eily, Lela R. PhD, MEd

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AJN, American Journal of Nursing: July 2020 - Volume 120 - Issue 7 - p 22-24
doi: 10.1097/01.NAJ.0000688188.28322.9c
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Abstract

Alcohol consumption during pregnancy can influence fetal development, causing lifelong behavioral, intellectual, and physical impairments known as fetal alcohol spectrum disorders (FASDs)—fetal alcohol syndrome (FAS) being the most severe type.1 Conservative estimates indicate that up to one in 20 U.S. schoolchildren may be affected by FASDs (see Figure 1),2 making these disorders more common than autism spectrum disorder, currently estimated to affect 1 in 54 children.3

Figure 1.
Figure 1.:
Alcohol use during pregnancy can lead to lifelong effects in children exposed prenatally. Image courtesy of the Centers for Disease Control and Prevention.

Although there is no known amount or type of alcohol that's considered safe to consume during pregnancy—and no safe time during pregnancy to consume it—high and sustained levels of alcohol use during pregnancy increase the likelihood of FASDs in children exposed prenatally.4 Therefore, because of alcohol's potential teratogenic effects, alcohol abstinence is recommended for pregnant women.5

Despite its recognized risks, however, alcohol use in pregnancy is still common. A recent analysis of 2015-2017 Behavioral Risk Factor Surveillance System (BRFSS) data found that an estimated 11.5% of pregnant women (one in nine) reported alcohol use and 3.9% reported binge drinking in the past 30 days.6 This represents a slight, though not statistically significant, increase from BRFSS 2011-2013 estimates of 10.2% of pregnant women reporting current drinking and 3.1% reporting binge drinking.7

Healthy People 2020 has set a target of increasing abstinence from alcohol among pregnant women from the 89.4% who reported no alcohol use in the past 30 days in the 2007-2008 National Survey on Drug Use and Health (NSDUH) to 98.3% by 2020.8 According to 2017-2018 NSDUH data, however, this target had not yet been met, as only 89.3% of pregnant women reported abstinence in the past month.8

ALCOHOL SCREENING AND BRIEF COUNSELING INTERVENTIONS

Nurses, patients, patients' partners, and families can discuss the risks of alcohol consumption during pregnancy and work together to make important health decisions. The U.S. Preventive Services Task Force (USPSTF) recommends screening for unhealthy alcohol use as a population-wide clinical preventive service.9, 10 This recommendation includes “screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions.”10 Findings of a systematic review by O'Connor and colleagues of 113 studies with over 300,000 participants support the use of alcohol screening and brief counseling for people who exceed recommended limits but do not have indications of alcohol dependence or severe alcohol use disorder.9

Alcohol screening and brief counseling begin with the administration of a validated screening instrument so the health care provider can objectively determine if a person is drinking excessively. Excessive drinking is defined as binge drinking (four or more drinks on one occasion for women or five or more drinks for men), heavy drinking (eight or more drinks in a week for women or 15 or more drinks for men), and any drinking by pregnant women or people younger than 21 years of age.11 (Suggested daily limits are up to one drink a day for women and up to two drinks a day for men.5) It's important for providers to use a screening instrument that will identify the patient's alcohol consumption patterns, inform ongoing patient education and monitoring, and quantify the person's alcohol use for reference during follow-up visits. Several validated alcohol screening tools exist, but many assess only for alcohol dependence and not for patterns of alcohol consumption,12 which is what determines whether a person should receive brief counseling or referral for treatment.

The World Health Organization's Alcohol Use Disorders Identification Test (AUDIT), a 10-item, validated alcohol screening instrument,13 is considered the gold standard12; an adapted version that includes U.S. standard drink sizes and drinking limits is known as the USAUDIT.14 The AUDIT 1-3 screener, which contains the first three questions of the USAUDIT, can be administered by itself in one minute or included as part of a longer health questionnaire. It identifies those who consume more than the recommended amount of alcohol on one occasion (or day) and is the first step in an alcohol screening algorithm developed by the Centers for Disease Control and Prevention (CDC) to determine which patients need more help (see Figure 2). For those who screen positive on the screener, the remaining seven items of the USAUDIT can be administered and answered in two to three minutes. The USPSTF notes, however, that the shorter, one-to-three-item screening instruments provide the most accurate results in adults 18 years of age and older.10

Figure 2.
Figure 2.:
The Alcohol Screening and Brief Intervention Algorithm, Including the AUDIT 1-3 (U.S.) Screener

Persons found to exceed recommended drinking limits are given a brief counseling intervention, and those with indications of severe alcohol use disorder are referred for treatment.12 A brief counseling session can be five to 15 minutes and generally consists of basic education on alcohol's harm to one's health, a comparison of the patient's pattern of alcohol consumption with the recommended limits, and/or feedback on the impact of the patient's alcohol consumption on her or his health and suggestions for reducing it if the patient chooses to do so.10, 12 Some counseling sessions include motivational interviewing techniques, but these are not a required component of the intervention.

ALCOHOL AND PREGNANT WOMEN—WHAT NURSES CAN DO

Universal implementation of alcohol screening and brief counseling, including to pregnant women and persons of reproductive age, could help with the achievement of a newly proposed Healthy People 2030 goal to increase alcohol abstinence among pregnant women.15 In their systematic review, O'Connor and colleagues found that alcohol screening and brief counseling sessions were associated with significantly increased maintenance of alcohol abstinence among pregnant women, with abstinence 2.26 times more likely in the intervention group than the control group.9 Nurses can talk to patients about the potential harms of excessive alcohol use and can routinely incorporate alcohol screening and brief counseling interventions into their work. Specifically, nurses can screen people of reproductive age using the USAUDIT and provide brief interventions to those who screen positive for excessive alcohol use, including pregnant patients, to help them reduce their consumption or abstain during pregnancy. If there is an indication of a severe alcohol use disorder, nurses can refer patients to treatment services.

Resources nurses can use to educate their patients and reduce alcohol use during pregnancy include the following: a CDC fact sheet about excessive alcohol use and risks to women's health (www.cdc.gov/alcohol/fact-sheets/womens-health.htm); the Substance Abuse and Mental Health Services Administration national helpline, (800) 662-HELP, available 24/7, 365 days a year; continuing education training and FASD prevention resources for health care providers (www.cdc.gov/FASDTraining); and e-learning FASD prevention courses specifically designed for nurses (www.npwh.org/courses; search for “Optimizing Preconception Health”). Finally, resources on implementing alcohol screening and brief counseling interventions can be found at www.cdc.gov/ncbddd/fasd/documents/alcoholsbiimplementationguide.pdf.

REFERENCES

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