Risk factors for alcohol use during pregnancy in a multistate area

A substance use screening instrument was used to select persons into two risk categories for drinking during pregnancy. About one-fourth (23.8%) of the survey participants were classified as high-risk women and the others were classified as low risk for drinking when pregnant. The participants (N=4676) for the study were sampled from four states (Montana, Minnesota, South Dakota, and North Dakota) that are a part of the Four-State Fetal Alcohol Syndrome (FAS) Consortium. Clinic sites for the administration of the prenatal screening instrument were selected in each state, based on geographic and known population characteristics. Univariate and multivariate statistical procedures were used to determine factors predictive of alcohol use. The purpose of the study was to assess risk factors for alcohol use in pregnant women. Women at high risk for alcohol use when pregnant tended to be younger, less educated, single, and unemployed. Demographic factors that were protective of drinking when pregnant were being married and full-time housewife status. Other variables associated with high-risk status for maternal alcohol use were past sexual abuse, current or past physical abuse, using tobacco, using other drugs, living with substance users, and having mates who were substance users. Other contributing factors for high-risk classification included feeling sad, believing that drinking any amount of alcohol while pregnant was acceptable, and being able to hold four or more drinks. Intervention programs that ameliorate risk factors and enhance protective attributes of high-risk pregnant women are needed.     

Alcohol use in pregnant low-income women

OBJECTIVE: The present study had two aims: (1) to examine the prevalence rates of prenatal alcohol consumption in a group of women participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in Southern California, with special emphasis on Hispanic women, and (2) to identify variables associated with postconception drinking in low-income minority women. METHOD: The study employed a cross-sectional survey that assessed alcohol use rates, demographic variables, and alcohol risk status. Participants were 826 pregnant women enrolled in the Public Health Foundation Enterprises (PHFE) WIC Program in Los Angeles and Orange counties, California. Pregnant women who enrolled self-administered a specially designed alcohol screener. RESULTS: Findings were that 24% of sample women were consuming alcohol post conception. Of that percentage, approximately two thirds drank prior to pregnancy recognition, and one third continued to drink after pregnancy was confirmed. Approximately 30% of white non-Hispanic, black non-Hispanic and English-speaking Hispanic women were found to drink post conception compared with 15.8% of Spanish-speaking Hispanic women. This finding supported recent research that suggests more acculturated Hispanic women tend to incorporate the drinking patterns of the larger U.S. population to a greater extent than less acculturated Hispanic women. Although a number of demographic variables differentiated women who were abstinent from those who were postconception drinkers, the best predictor of postconception alcohol consumption was the woman's high-risk drinking score as measured by the TWEAK (sensitivity = 70.1%, specificity = 88.5%). CONCLUSIONS: Results suggest the importance of screening low-income minority pregnant women in a community setting so that interventions can be initiated to prevent fetal alcohol syndrome and related conditions.     

Health care provider advice and risk factors associated with alcohol consumption following pregnancy recognition

OBJECTIVE: This study examined the extent to which pregnant women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were counseled by their health care providers to stop drinking alcohol during pregnancy. A second purpose was to identify characteristics associated with alcohol consumption postrecognition of pregnancy. METHOD: The sample consisted of 279 women who continued to drink after learning they were pregnant. Measures of provider advice on alcohol consumption, demographic characteristics, caffeine intake, smoking, other drug use, alcohol risk (using the TWEAK scale), and depressive symptoms on the Center for Epidemiological Studies Depression Scale (CES-D) were collected. RESULTS: Sixty-two percent of women had significantly high TWEAK scores, and 60% scored within the clinical range for depression (CESD > or =16). Sixty percent of sample women had been advised by their care providers not to drink alcohol during pregnancy. Women who were most likely to receive advice were black non-Hispanic and Hispanic, were Spanish speaking, were less educated, were on public assistance, and had a higher number of alcohol-related risk behaviors. Advanced age, public assistance, caffeine use, smoking, and elevated TWEAK and CESD scores predicted elevations in alcohol consumption rates. CONCLUSIONS: Although advice to stop drinking during pregnancy was provided to 60% of this sample, women continued to drink following pregnancy recognition, with alcohol consumption rates highly associated with sociodemographic and psychological factors, namely maternal depression. Because elevations in alcohol consumption during pregnancy are associated with poorer developmental outcomes for children, further efforts are needed to better address social and mental health factors that influence consumption.     

History of Physical Abuse and Periconceptional Drinking in Pregnant Women

This study examines the relationship between physical abuse and periconceptional drinking in women presenting to a mid-Atlantic, urban hospital-based OB/GYN clinic serving a largely indigent population between April 2003 and May 2004. During their first prenatal visit, 308 women completed a screening battery that included the Abuse Assessment Screen (AAS) and measures of alcohol use, including the CAGE, T-ACE, TWEAK, and the PRIME-MD Patient Health Questionnaire (PHQ). Bivariate analyses, including odds ratios (ORs) and 95% confidence intervals (CIs), revealed that women with a history of physical abuse were more likely to report drinking alcohol within the 3 months prior to their prenatal care visit and were significantly more likely to meet criteria for risk drinking on multiple measures. A history of physical abuse appears to be associated with higher self-reported rates of periconceptional drinking in pregnant women. Study findings support the need for assessment of abuse history as a potential risk factor for alcohol use in pregnant women.     

History of physical abuse and periconceptional drinking in pregnant women

This study examines the relationship between physical abuse and periconceptional drinking in women presenting to a mid-Atlantic, urban hospital-based OB/GYN clinic serving a largely indigent population between April 2003 and May 2004. During their first prenatal visit, 308 women completed a screening battery that included the Abuse Assessment Screen (AAS) and measures of alcohol use, including the CAGE, T-ACE, TWEAK, and the PRIME-MD Patient Health Questionnaire (PHQ). Bivariate analyses, including odds ratios (ORs) and 95% confidence intervals (CIs), revealed that women with a history of physical abuse were more likely to report drinking alcohol within the 3 months prior to their prenatal care visit and were significantly more likely to meet criteria for risk drinking on multiple measures. A history of physical abuse appears to be associated with higher self-reported rates of periconceptional drinking in pregnant women. Study findings support the need for assessment of abuse history as a potential risk factor for alcohol use in pregnant women.     

Brief intervention for prenatal alcohol use: the role of drinking goal selection

The behavioral problems and cognitive deficits resulting from even small amounts of prenatal alcohol exposure can be significant and enduring but completely preventable. The purpose of this study was to examine the impact of a prenatal drinking goal selected during a brief intervention for 115 pregnant women and their partners on subsequent consumption. Higher proportions of women having their first pregnancy chose abstinence as a goal over drinking reduction. Goal selection was highly predictive of subsequent drinking behavior. Interestingly, the participants who were abstinent at enrollment and who chose to remain abstinent had the highest rates of abstinence. In contrast, the women who chose cutting down on drinking were the least likely to drink less subsequently, despite recognizing more situations putting them at risk for drinking and identifying more alternatives to consumption. We conclude that goal choice in behavioral self-management of alcohol use by pregnant women is critical.     

Prenatal alcohol exposure assessment: multiple embedded measures in a prenatal questionnaire

Alcohol exposure during pregnancy is a well-recognized public health problem. Accurate assessment of prenatal alcohol exposure is especially important to identify women in need of intervention. In this study, a 36-item prenatal questionnaire was utilized to survey a representative sample of prenatal care providers to examine prevalence rates of exposure. The questionnaire included three common screening tools for alcohol use during pregnancy and the items necessary to establish a maternal risk profile. In North Dakota, 1081 pregnant women were included in the sample. Eighty (7.4%) were Native American and 952 (88%) were White. The TWEAK screening tool was positive for 253 (23.4%) of the women. Native American women had a 71% increase in positive TWEAK screenings compared to White women. Logistic regression was used to develop a high-risk model. The data from prenatal care can also be used for maternal risk stratification. Early identification can provide opportunity for early interventions to decrease total exposure during pregnancy and to improve the outcome for the child.     

Screening instruments for alcohol problems: a comparison of cut points between Mexican American and Mexican patients in the emergency room

The performance of alcohol use disorder screening instruments (CAGE, BMAST, AUDIT, TWEAK) at various cut points were compared between a Mexican American emergency room (ER) sample (n = 586) and a sample of ER patients in Mexico (n = 1,417) using ICD-10 and DSM-IV criteria for alcohol dependence and harmful drinking/abuse by gender and injury status. Lowering cut points improved instrument performance substantially for females in both samples. Further research is needed to explore instrument performance by gender and level of acculturation.     

A Comparison of Alcohol Consumption Intentions Among Pregnant Drinkers and Their Nonpregnant Peers of Child-Bearing Age

Objective: To investigate alcohol consumption intentions among Australian women of childbearing age by pregnancy status. Methods: Three national online surveys were conducted with adult drinkers who consume an alcoholic beverage at least two days per month. Data from female respondents of childbearing age were analyzed according to pregnancy status: pregnant (n = 101), possibly pregnant (n = 178), and not pregnant (n = 1,957). Results: Pregnant drinkers were significantly more likely than possibly pregnant and nonpregnant drinkers of child-bearing age to report that they should and will reduce their alcohol consumption. Results showed that 33% of the pregnant women, 32% of the nonpregnant women, and 39% of the possibly pregnant women reported intending to drink five or more standard drinks on a single occasion in the following two weeks. Older pregnant women exhibited higher rates of heavy drinking intentions and lower intentions to reduce their consumption relative to younger pregnant women. Conclusion: Despite current alcohol consumption guidelines recommending abstinence while pregnant, pregnant respondents exhibited heavy episodic drinking intentions comparable to those of their nonpregnant peers. Implications: There is a need to increase public awareness of current alcohol guidelines for pregnant women. Older women of childbearing age and those planning a pregnancy may require particular attention.     

Screening Instruments for Alcohol Problems: A Comparison of Cut Points between Mexican American and Mexican Patients in the Emergency Room

The performance of alcohol use disorder screening instruments (CAGE, BMAST, AUDIT, TWEAK) at various cut points were compared between a Mexican American emergency room (ER) sample (n = 586) and a sample of ER patients in Mexico (n = 1,417) using ICD-10 and DSM-IV criteria for alcohol dependence and harmful drinking/abuse by gender and injury status. Lowering cut points improved instrument performance substantially for females in both samples. Further research is needed to explore instrument performance by gender and level of acculturation.     

Prospective identification of pregnant women drinking four or more standard drinks (> or = 48 g) of alcohol per day

We aimed to identify drinking rates in a prospectively identified cohort of pregnant women, and subsequently, to identify the drinkers of 48 g or more alcohol/day among them, by using complementary methods for verifying self-reported drinking habits. A research team of social workers and health professionals at the Maipú Clinic, located in a lower middle class neighborhood of Santiago, Chile, conducted interviews of women attending a prenatal clinic between August 1995 and July 2000. Women whose interview responses met predefined criteria (identified in the text) were further evaluated by home visits. We interviewed 9,628 of 10,917 (88%) women receiving prenatal care. By initial interview, 42.6% of women reported no drinking, 57.4% some alcohol consumption, and 3.7% consuming at least one standard drink (15 mL of absolute alcohol) per day. Of the 887 women who had home visits, 101 were identified as consuming on average at least 4 drinks/day (48 g). To determine the best home visit questionnaire items for identifying those drinking at least 4 drinks per day, 48 women who openly admitted drinking this amount were compared with 786 women who were not considered drinkers after the home visit. The 48 self-reported 48 g/day drinkers were significantly more likely to get tipsy when drinking before (p = 0.01) or during (p < 0.0001) pregnancy, to have started drinking at a younger age (p = 0.007), or to exhibit signs of low self-esteem (p < 0.0001), sleep or appetite problems (p < 0.0001), bad interpersonal relationships (p < 0.0001) or having family members with fetal alcohol syndrome features (p < 0.009). In conclusion, using complementary methods of alcohol misuse ascertainment during pregnancy, we found that at least 1% of pregnant women in a Santiago, Chile, clinic population were drinking at levels that are clearly dangerous to the fetus (48 g/day or more). We identified specific interview questions that may help screen for alcohol use of 48 g/day or more in pregnant women.     

Screening for alcohol problems in two emergency service samples in Poland: comparison of the RAPS4, CAGE and AUDIT

Prior research on alcohol-related problems among emergency service patients in Poland found substantial alcohol involvement on the part of injured males, suggesting emergency services may be a productive venue for identifying patients who could benefit from a brief intervention or referral for treatment. Performance of the RAPS4, CAGE and AUDIT against ICD-10 and DSM-IV criteria for alcohol dependence and for alcohol abuse/harmful drinking was compared in probability samples of emergency service patients from two regions of Poland. Sensitivity of the RAPS4 and AUDIT was significantly better than the CAGE for alcohol dependence among males in Warsaw, but specificity was poorer. Among females, although numbers were small, sensitivity for alcohol abuse/harmful drinking and for alcohol dependence or abuse/harmful drinking was significantly better for the RAPS4-QF than for the CAGE or AUDIT at a cut point of 8 across both sites. Performance of the AUDIT at a cut point of 3 was similar to the RAPS4-QF for females. Among males, sensitivity was higher but specificity considerably lower for the RAPS4-QF compared to the CAGE at a cut point of 1 or for the AUDIT at a cut point of 8. Alternate cut points for the AUDIT optimized performance. Findings suggest some regional and gender differences in performance of screening instruments in these Polish samples, but no instrument or cut point is optimal in identifying those with alcohol use disorders. Additional cross-cultural research is needed to evaluate the performance of instruments, especially among females with alcohol use disorders.     

Patterns of alcohol intake of pregnant and lactating women in Perth, Australia

Introduction and Aims. Australian alcohol consumption data for women during the period of pregnancy and lactation is limited. The purpose of this paper is to provide current alcohol consumption data for pregnant and lactating women in Perth, Western Australia (WA). Data were collected from 587 women between mid-September 2002 and mid-July 2003. Design and Methods. Women from two public hospitals with maternity wards in the Perth metropolitan area completed a self-administered baseline questionnaire while in hospital or shortly after discharge. All women, regardless of their chosen infant feeding method, were followed-up by telephone interview at 4, 10, 16, 22, 32, 40 and 52 weeks postpartum. Data were analysed to determine alcohol use patterns of the women during the period of pregnancy and lactation and results were compared to national guidelines for alcohol consumption. Results. Approximately 32% of women stopped drinking alcohol during pregnancy. A remaining 35% of pregnant women consumed alcohol during pregnancy, with 82.2% of these women consuming up to two standard drinks per week. At 4, 6 and 12 months postpartum, 46.7%, 47.4% and 42.3% of breastfeeding women were consuming alcohol, respectively. Discussion and Conclusions. The majority of breastfeeding women consumed up to two standard drinks per week, which is within levels recommended by national authorities. There is, however, a small proportion of women consuming alcohol at levels above national recommendations for pregnancy and lactation. The development of 'safe' alcohol intake practices, within national recommendations, during the postnatal period would remove any potential health risks to the infant from alcohol exposure at this vulnerable growth stage. [Giglia RC, Binns CW. Patterns of alcohol intake of pregnant and lactating women in Perth, Australia. Drug Alcohol Rev 2007;26:493 - 500]     

Unexpectedly high prevalence of alcohol use among pregnant Swedish women: failed detection by antenatal care and simple tools that improve detection

OBJECTIVE: We examined the use of alcohol during early pregnancy in urban Swedish women, the ability of Swedish antenatal care to identify alcohol-related risk pregnancies and the utility of some potential tools for improving its performance. METHOD: Women attending regular antenatal care were randomized to regular assessment only (control, n = 156) or intensified screening (intervention, n = 147). In the intervention group, alcohol use was determined using the Timeline Followback (TLFB) interview, alcohol use habits with the Alcohol Use Disorder Inventory Test (AUDIT), and biomarkers for alcohol use were analyzed. Data were typically obtained in pregnancy week 12. RESULTS: In the intervention group as a whole, average absolute alcohol consumption during the first 6 weeks of pregnancy was low but highly variable (mean [SD] = 24.9 [50.5] g/week; 4.8 [6.0] episodes for the entire 6 week period); 22 women (15%) drank at levels exceeding 70 g/week during any 2 or more weeks and/or in a heavy episodic drinking pattern, 60 g/episode, on 2 or more episodes. The AUDIT had a moderate sensitivity (54%) to identify these subjects. Biomarkers identified subjects with somatic illness rather than high alcohol consumption. In the control group, only 4 (3%) were identified as using alcohol, indicating a probable underestimation of alcohol use by regular antenatal screening procedures (p = .0001). CONCLUSIONS: An unexpected proportion of pregnant women in urban Sweden consume alcohol at levels likely to produce adverse effects. Regular antenatal care did not identify most of these risk pregnancies. The TLFB identified pregnant women with risk use of alcohol during pregnancy who were only partly identified by analyzing prepregnancy alcohol use patterns with the AUDIT. Elevated laboratory markers likely indicated somatic illness rather than harmful drinking.     

Opinions of non‐pregnant New Zealand women aged 16–40 years about the safety of alcohol consumption during pregnancy

Introduction and Aims. Premenopausal women's opinions on the safety of alcohol consumption during pregnancy are not well documented. This study aims to assess the opinions of New Zealand women on the safety of alcohol consumption in pregnancy and the sociodemographic and lifestyle factors associated with these opinions. Design and Methods. A nationwide, cross‐sectional survey was conducted in 2005 on a random sample of 1109 non‐pregnant women aged 16–40 years. Data were collected via an interviewer‐administered questionnaire using a web‐assisted telephone interviewing system. Results. Overall, 44% (95% confidence interval 41–47) of women surveyed were of the opinion that no alcohol is safe in pregnancy. Those who stated that no alcohol is safe in pregnancy were more likely to be of Pacific Island ethnicity (P < 0.05) and abstainers (P < 0.001). Women who drank more than two standard drinks of alcohol on a typical occasion and/or who binged were more likely to be of the opinion that ‘more than one standard drink’ of alcohol is safe on a typical drinking day during pregnancy (P < 0.001). Discussion and Conclusions. The association of drinking style with opinions about the safety of alcohol consumption in pregnancy accentuates the need for public health education to reduce risky drinking behaviours in this population. Such efforts may also address the risk associated with many women unintentionally drinking in early pregnancy, especially if the pregnancy is unplanned.[Parackal SM, Parackal MK, Harraway JA, Ferguson EL. Opinions of non‐pregnant New Zealand women aged 16–40 years about the safety of alcohol consumption during pregnancy. Drug Alcohol Rev 2009]     

Stages of change and prenatal alcohol use

This study evaluated stage of change as a predictor of alcohol use in a sample of 301 pregnant women who were either in the precontemplation (62%) or in the action (38%) stage of change in their first trimester. Stage of change distinguished between different patterns of alcohol consumption before and after pregnancy. Those in the precontemplation stage drank more per episode and more often before pregnancy than those in the action stage. The precontemplation group also had a significantly greater quantity of alcohol after pregnancy. However, stage of change did not directly predict subsequent prenatal alcohol use. Previous alcohol use, age, and education were the most significant predictors of prenatal drinks per drinking day. Temptation to drink alcohol was the best predictor of prenatal drinking frequency after study enrollment. Women in both stages of change reduced the quantity and the frequency of their alcohol consumption while pregnant and achieved comparable rates of abstinence.     

Prospective Identification of Pregnant Women Drinking Four or More Standard Drinks (≥ 48 g) of Alcohol Per Day

We aimed to identify drinking rates in a prospectively identified cohort of pregnant women, and subsequently, to identify the drinkers of 48 g or more alcohol/day among them, by using complementary methods for verifying self-reported drinking habits. A research team of social workers and health professionals at the Maipú Clinic, located in a lower middle class neighborhood of Santiago, Chile, conducted interviews of women attending a prenatal clinic between August 1995 and July 2000. Women whose interview responses met predefined criteria (identified in the text) were further evaluated by home visits. We interviewed 9,628 of 10,917 (88%) women receiving prenatal care. By initial interview, 42.6% of women reported no drinking, 57.4% some alcohol consumption, and 3.7% consuming at least one standard drink (15 mL of absolute alcohol) per day. Of the 887 women who had home visits, 101 were identified as consuming on average at least 4 drinks/day (48 g). To determine the best home visit questionnaire items for identifying those drinking at least 4 drinks per day, 48 women who openly admitted drinking this amount were compared with 786 women who were not considered drinkers after the home visit. The 48 self-reported 48 g/day drinkers were significantly more likely to get tipsy when drinking before (p = 0.01) or during (p < 0.0001) pregnancy, to have started drinking at a younger age (p = 0.007), or to exhibit signs of low self-esteem (p < 0.0001), sleep or appetite problems (p < 0.0001), bad interpersonal relationships (p < 0.0001) or having family members with fetal alcohol syndrome features (p < 0.009). In conclusion, using complementary methods of alcohol misuse ascertainment during pregnancy, we found that at least 1% of pregnant women in a Santiago, Chile, clinic population were drinking at levels that are clearly dangerous to the fetus (48 g/day or more). We identified specific interview questions that may help screen for alcohol use of 48 g/day or more in pregnant women.     

An alternative to standard drinks as a measure of alcohol consumption

Despite the field's longstanding concern with underreporting of alcohol consumption, traditional survey questions encourage error because respondents often must calculate their number of drinks based on standard drink sizes that often do not match their own drinking style. This study considered how often respondents' self-defined drink sizes matched a 'standard' drink size based on approximately 12 g of ethanol for six different beverages. We also studied whether respondents could accurately judge the size of their drinks. Subjects were recruited and interviewed at urban prenatal clinics, health clinics, and via snowball referrals and community outreach in Los Angeles and the San Francisco Bay Area. Because of the urgency of accurate measurement of consumption during pregnancy, urban pregnant women from the groups most at risk for Fetal Alcohol Syndrome, Native Americans (n = 102) and African Americans (185), were targeted. A small comparison group of urban pregnant white women (n = 34) was included. One-hour in-person interviews were conducted. Self-defined drink sizes were determined for each beverage consumed, using models and photographs of vessels. Frequent drinkers and the majority of women who reported drinking higher alcohol content beverages reported drinking larger-than-standard drink sizes. The median size of a malt liquor drink among the daily drinkers was almost three times as large as the standard, their fortified wine drinks were four times the standard, and their spirits drinks were six times the standard size. The majority of drinkers of each beverage were unable to accurately judge the size of their drinks, underestimating the number of fluid ounces by about 30%. Although the vessels methodology used here must be refined and tested further on other populations (e.g., men, nonpregnant women, and all ethnic groups), results suggest that determination of risk levels should be based on survey data that takes into consideration the beverage mix and the actual size of respondents' alcohol drinks.