A survey of Obstetricians and Gynecologists on their patients’ alcohol use during pregnancy

ArticleinObstetrics and Gynecology 95(5):756-63 · June 2000with 58 Reads
Abstract
To examine knowledge, attitudes, current clinical practices, and educational needs of obstetrician-gynecologists regarding patients' alcohol use during pregnancy. A 20-item, self-administered questionnaire on patients' prenatal alcohol use was sent to 1000 active ACOG fellows. Responses were analyzed using univariate and multivariate statistical techniques. Of the 60% of the obstetrician-gynecologists who responded to the survey, 97% reported asking their pregnant patients about alcohol use. When a patient reports alcohol use, most respondents reported that they always discuss adverse effects and always advise abstinence. One fifth of the respondents (20%) reported abstinence to be the safest way to avoid all four of the adverse pregnancy outcomes cited (ie, spontaneous abortion, central nervous system impairment, birth defects, and fetal alcohol syndrome); 13% were unsure about levels associated with all of the adverse outcomes; and 4% reported that consumption of eight or more drinks per week did not pose a risk for any of the four adverse outcomes. The two resources that respondents said they needed most to improve alcohol-use assessment were information on thresholds for adverse reproductive outcomes (83%) and referral resources for patients with alcohol problems (63%). Efforts should be made to provide practicing obstetrician-gynecologists with updates on the adverse effects of alcohol use by pregnant women and with effective methods for screening and counseling women who report alcohol use during pregnancy.
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    Many common misconceptions about prenatal exposure to alcohol still exist in the minds of bom the public and professional communities. Many of these misconceptions possess striking similarities to misperceptions about women who abuse alcohol. This paper attempts to do away with some widespread erroneous ideas related to alcohol abuse and its effects. Research results in the areas of drug treatment and developmental outcomes are reviewed and recommendations for service provision to both mothers with alcohol abuse problems and individuals with Fetal Alcohol Spectrum Disorder are made.
  • In the February issue of Acta Obstetricia et Gynecologica Scandinavica Rausgaard et al. presented results from a survey of 608 pregnant Danish women (88% of those invited), who accepted anonymous urinary screening for "substance abuse" (1). Diagnostic confirmation was performed by gas chromatography/mass spectrometry to confirm that the tested substance was the cause of the positive result. Forty-two urine samples were positive on urinary screening, of which 22 samples proved positive for opioids or cannabis (3.6%), while 20 could not be confirmed. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
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    Objective: to utilise qualitative data from investigation of the screening tool ASSIST Version 3.0 with pregnant women to help determine its appropriateness for this cohort, thus informing potential innovations to enhance the questionnaire׳s utility. Design: pregnant women were co-administered the ASSIST Version 3.0 and three established substance use questionnaires (the T-ACE for alcohol, the Timeline FollowBack for cannabis and the Revised Fagerstrom Questionnaire for tobacco). Setting: antenatal clinics and the antenatal ward of the Women׳s and Children׳s Hospital, Adelaide, South Australia. Participants: 104 pregnant substance-users. Measurements and findings: as well as the quantitative date (reported elsewhere), rich qualitative data documenting participants' perspectives and experiences in antenatal care were thematically analysed. Women constantly reported friends and family urging them to stop use. Although care providers also advocated cessation or curtailment of use, this advice was reported as unpredictable, with only some providers strongly attuned to such recommendations. Some women voiced suggestions for the appropriate level of provider advice. While pregnancy was often reported as a motivator for changing substance-using behaviour, others reported continued attachment to use which was clearly linked to dependence. Those who reported successful control of use were in contrast to others who were more pragmatic, sceptical in relation to attributable harms, and disinterested in change. There were limited reports of experiences of discrimination directed to pregnant substance users. However, those instances were clearly linked with subsequent lack of honest discussions with care providers, resulting in an absence of appropriate support. Key conclusions: current absence of universal screening for substance use has the potential for less than optimal consequences for both mother and baby. Implications for practice: appropriate screening accompanied by honest, non-judgmental dialogue can guide the necessary interventions to achieve better outcomes. The recent development of the more concise and easier to administer ASSIST-LITE was partly informed by this investigation.
  • Book
    Substance Use: Obstetric and Gynecologic Implications Key Points ■ Substance use, abuse, and dependence affect women and men differently and can have serious implications for women’s health. Among them are adverse effects on reproductive function and pregnancy. ■ Key areas in which obstetrician–gynecologists can have an effect are prevention, screening, testing, brief intervention, and referral. ■ Obstetrician–gynecologists are responsible for prescribing appropriately, encouraging healthy behaviors by providing appropriate information and education, and identifying and referring patients already abusing drugs. ■ Asking questions of all patients about their history and levels of use of alcohol and other drugs helps to indicate when further investigation is needed. ■ Substance abuse and dependence occur across the lifespan and without regard to ethnic background, socioeconomic status, or sexual orientation. ■ Women who abuse substances rarely abuse a single substance. Those who abuse illicit substances frequently also abuse tobacco or alcohol or both. The potential effect of multiple substance abuse must be taken into account when attempting to evaluate the effects of individual substances on the fetus or on pregnancy outcome. ■ Fetal alcohol syndrome (FAS) is the most common preventable cause of mental retardation; FAS and other alcohol-related defects and disorders are 100% preventable if a woman does not drink during pregnancy. ■ Education and brief intervention preformed by the obstetrician–gynecologist can be very effective in reducing alcohol-exposed pregnancies. ■ Comprehensive prenatal care has been shown to ameliorate many of the maternal and neonatal complications associated with substance abuse.
  • Chapter
    The liver is one of the most important organs of the body which undergoes a significant change during pregnancy. Various enzymes as well as clotting factors are formed in the liver; it is also responsible for metabolism of different chemicals in the body. Liver disease is associated with clotting abnormalities as well as metabolism of drugs given for medical reasons. These obviously will affect the anesthetic of choice and technique.
  • Article
    Background: Foetal alcohol spectrum disorder (FASD) is the main non-genetic cause of mental disability in children. "The zero alcohol rule" during pregnancy is recommended but no tracking tool is available to perinatal professionals. In order to improve prevention of FASD in Lorraine, the Lorraine Perinatal Network conducted an assessment of current practices by perinatal professionals and proposed a tool to facilitation detection of FASD. Materials and Methods: The proposed tool is a self-assessment questionnaire combining the AUDIT-C and T-ACE procedures. One hundred randomly selected professionals and all midwives of the Department of Maternal and Child Health (Meurthe-et-Moselle) were asked about their practices before filling in the self-assessment questionnaire. Results: Midwives (98%) were significantly more involved than doctors (53%) (p < 0.0001). 32% of the professionals interviewed encountered difficulties talking about alcohol and 30% were willing to be trained in this issue. The majority of professionals who tested the tool found it to be appropriate. Pregnant women easily answered the questionnaire. Only 15 women reported drinking alcohol during pregnancy, while the self-administered survey revealed that 38 women required specific monitoring. Discussion: It remains difficult to encourage active participation of professionals, especially doctors, in this field. Professionals expressed the need for an aid to detection of high-risk behaviours. The proposed tool facilitates detection, but there is still room for improvement. Conclusion: The Perinatal Network must find new means to mobilize professionals, organize training programmes and improve the tool so that drinking can be systematically discussed during prenatal visits.
  • Article
    Background: Although drinking and smoking during pregnancy can have hazardous effects to exposed children, a certain number of pregnant women continues to consume alcohol and nicotine. It was investigated whether physicians and midwifes in Switzerland ask pregnant women about their drinking and smoking habits. Method: A self-report questionnaire was used to assess whether pregnant women were screened for alcohol and nicotine consumption by physicians or midwifes. Data of 368 women were included in the analyses. Results: 30.0% reported drinking alcohol at least once a month after pregnancy recognition, 2.2% reported binge drinking and 10.1% were smokers. Only in 36.1% of the sample drinking during pregnancy was addressed. The subgroup, which drank alcohol, was not more likely to be asked about drinking habits than non-drinkers. In contrast, smoking was addressed in 66.3% of the total sample and it was addressed in nearly 90% of the smokers' subgroup. Conclusion: A change in the screening practice in prenatal care with regard to alcohol drinking during pregnancy is recommended. Brief interventions can reduce drinking during pregnancy.
  • Article
    CONTEXT: Women's behaviors before and during pregnancy con affect their infants' health. Particularly because many births in the United States are unintended, it is important to understand women's health behaviors and pregnancy planning status before they become pregnant. METHODS:A telephone survey of nonpregnant women of childbearing age who belonged to a Southern California managed care plan was conducted from 1998 through 2000. Survey data were analyzed in logistic regression models assessing differences in selected behaviors between women planning pregnancy and others. RESULTS. Compared with women not planning pregnancy, those planning pregnancy within the next year ("soon") were less likely to report smoking (odds ratio, 0.6), and more likely to report taking a multivitamin regularly (1.4) and having had a health core visit in the past year (1.6). Women planning a pregnancy more than one year in the future hod elevated odds of reporting alcohol use (1.4); they were similar to women not planning pregnancy with respect to multivitamin use and smoking behavior. Women planning pregnancy soon were more likely than women not planning pregnancy to report that a health core professional had talked to them about taking a vitamin or mineral supplement (1.6). CONCLUSIONS: All women of childbearing age need information about the importance of engaging in healthy behaviors. Health care providers who have regular contact with such women should send clear messages about the adverse effects of alcohol and smoking during pregnancy and the importance of taking a multivitamin regularly, regardless of women's pregnancy plans, before they become pregnant.
  • Introduction: In 1999, Danish health authorities modified their recommendation to pregnant women condoning some alcohol intake. In 2007, the recommendation was changed to one of alcohol abstention. We aimed to assess changes in average alcohol intake (drinks/week) and alcohol binge drinking in early pregnancy from 1998 to 2013 in relation to the changes in official recommendations in 1999 (condoning some intake) and 2007 (abstention). Material and methods: All Danish speaking pregnant women attending routine antenatal care at the Department of Obstetrics and Gynaecology, Aarhus University Hospital, Denmark, between September 1998 and June 2013 were invited to participate. During the study period 68,395 pregnant women filled in a self-administered questionnaire at gestational week 11 (median). From 1998, questions on binge drinking included data on the number of binge episodes (≥5 drinks on a single occasion), and the timing (gestational week) of these episodes. Additional questions on binge drinking defined as ≥3 drinks on a single occasion were asked separately from 2000. A question assessed the average number of alcohol containing drinks per week the woman consumed currently at the time of filling in the questionnaire RESULTS: From 1998-2013 the proportion of women reporting no alcohol intake increased from 31.2% to 83.3% (p<0.001), the main decline occurring between 1998 and 2007. The proportion of binge drinkers decreased (p<0.001) but remained more stable across the period CONCLUSION: The decline in the proportion of pregnant women consuming alcohol occurred independently of official recommendations. Increasing national and international awareness may partly explain the changes. This article is protected by copyright. All rights reserved.
  • Article
    Full-text available
    Objetivo: diversos estudios señalan un déficit y una demanda de información entre distintos profesionales de la salud en relación con las características de los trastornos vinculados a la exposición prenatal al alcohol y su prevención. Este documento busca hacer una reflexión sobre los aspectos más relevantes por considerar en la detección y el manejo del consumo de alcohol durante la gestación.Materiales y métodos: con base en la revisión de la evolución histórica de la investigación sobre los trastornos vinculados a la exposición prenatal al alcohol se da respuesta a las siguientes preguntas: 1) ¿Cuáles son los criterios diagnósticos actuales de los trastornos del espectro alcohólico fetal (TEAF)?, 2) ¿cuál es la prevalencia del síndrome de alcoholismo fetal (SAF) y otros TEAF?, 3) ¿cuál ha sido la evolución de las recomendaciones internacionales respecto al consumo de alcohol durante la gestación?, 4) ¿qué estrategias de prevención existen actualmente? Para esto se realiza una extensa revisión de la investigación publicada a nivel internacional.Resultados: la investigación moderna respecto a la exposición prenatal al alcohol evidencia que esta puede dar lugar a un amplio espectro de problemas. Las dificultades para establecer una dosis de alcohol segura durante la gestación han conducido a la modificación progresiva de las recomendaciones respecto del consumo durante este periodo, desde el consumo moderado hasta la abstinencia.Conclusión: el impacto y la magnitud de esta problemática exigen el desarrollo de planes de prevención específicos. Su implementación demanda la formación continua de los profesionales que trabajan en cuidados periconcepcionales y perinatales.
  • Article
    Full-text available
    Prenatal exposure to alcohol is a leading preventable cause of birth defects and developmental disabilities. Individuals exposed to alcohol during fetal development can have physical, mental, behavioral, and learning disabilities, with lifelong implications. These conditions are known as fetal alcohol spectrum disorders (FASDs). Health care professionals play a crucial role in identifying women at risk for an alcohol-exposed pregnancy and in identifying the effects of prenatal alcohol exposure among individuals. The Centers for Disease Control and Prevention's National Center on Birth Defects and Developmental Disabilities has funded four universities as FASD Regional Training Centers (RTCs). The RTCs, in collaboration with the CDC and the National Organization on Fetal Alcohol Syndrome, are developing, implementing, and evaluating educational curricula for medical and allied health students and practitioners and seeking to have the curricula incorporated into training programs at each grantee's university or college, into other schools throughout the region, and into the credentialing requirements of professional boards. This article highlights some of the innovative training approaches that the RTCs are implementing to increase knowledge regarding FASDs and the ability of health professionals to identify, treat, and prevent these conditions.
  • Research
    Full-text available
    It is well recognized that heavy alcohol exposure during pregnancy carries significant risk for developmental disabilities in children, including fetal alcohol spectrum disorder (FASD). However, over the past few years several publications have appeared in the peer-reviewed literature from two large-scale, longitudinal studies looking at the impact of low to moderate alcohol use in pregnancy on child outcomes. These studies have reported little or no measurable effect of low to moderate prenatal alcohol exposure on child outcomes. This has generated headlines in the lay press and sown confusion among women and health professionals who are receiving two very different messages from the research community. This provoking presentation offers participants a unique opportunity to consider a balanced summary of the clinical evidence supporting both sides of this issue, and supports arguments in favour of each of the following statements: 1. The existing clinical evidence supports the conclusion that light to moderate maternal consumption of alcohol during pregnancy is not a significant risk factor for child development. 2. The existing clinical evidence supports the conclusion that light to moderate maternal alcohol use during pregnancy is a significant risk factor for child development. Reconciling the discordant nature of these expert positions, the presentation concludes with a summary of recommendations and precautions pertaining to policy that have been drawn from the current and emerging literature base.
  • Article
    Computer interviewing to obtain sensitive information is not a new concept. However, concerns about the acceptance of computers in disadvantaged populations with potentially low literacy led us to combine audio- and touch-screen technologies with an audio computerized self-report interview to obtain information about alcohol use. This study evaluated acceptance and ease of use by a disadvantaged population of pregnant women in the District of Columbia. Patients attending an initial visit at prenatal clinics answered questions anonymously about their consumption of alcoholic beverages and other personal information. The questionnaire was programmed on a laptop computer. The computer administered the recorded questions via earphones, as well as displayed them on the screen, and patients answered by touching the computer screen. Results were immediately available. A total of 507 women were interviewed, who were primarily African American, non-Hispanic, and never married. Nearly 24% did not complete a high school education, 43% were unemployed, and 30% received public assistance. Most of the women (59%) used computers occasionally (a few days a month) or never. Nearly all patients (96%) reported that the computer was not difficult to use, and approximately 90% liked answering the questions by computer. The study demonstrates that using computers to screen for alcohol use in disadvantaged pregnant populations is feasible and acceptable to the patients.
  • Article
    Within the framework of addictive behaviours, a descriptive step is often the introduction necessary for any comprehensive step. Thus, epidemiology is a tool which turns out in particular when it is a question of considered i) the existence of addictifs behavior in a specific population and to measure the relevance of the notion of "harmful use" in nosography, ii) the relevance of use of one pathology as a model of study of addictifs mechanisms. So, we estimated at first the existence of addictif behaviours in a specific population "the pregnant women". It seems that self-reports are easily useful and provide a strong adhesion of the participants. The biological markers of alcohol consumption are not helpful contrary to biological markers of tobacco exposure which revealed a higher presence of environmental tobacco smoke. This survey also reveals that half of women in Auvergne consume at least one drink of alcohol during their pregnancy and that the major consequence of this consumption : the Fœtal Alcohol Syndrome (FAS) has been found to be present in at least 1.8 of 1000 live births. So this epidemiological study allowed measure of indicators of sanitary interest for a social and preventive Medicine and targeted programs for public health. Secondly, we estimated the addictif profile of another specific population "Parkinson's disease (PD) patients" in comparison to general population. The secondary objective is to better define tools at disposal. We noticed that the hypersexuality or the pathological gambling do not seem to be overrepresented behaviours in PD patients whereas dopamine dysregulation syndrome (DDS) is frequent. In prospect of this research, it seemed that reliable tools of evaluation particularly on hypersexuality remain to be developed. Furthemore to this epidemiological research, PD patients can represent a model to better understand the functioning of addictive behaviours.
  • Article
    Fetal Alcohol Spectrum Disorders (FASDs) represent a continuum of development disabilities associated with maternal consumption of alcohol during pregnancy. This spectrum of disorders, which includes the Fetal Alcohol Syndrome (FAS), is characterized by a wide range of physical, cognitive, and behavioral impairments. Estimates of the number of live births in the United States meeting criteria for a diagnosis of FAS range from .5 to 2 infants per 1,000, with the prevalence of the entire continuum of FASDs estimated to be 1 in 100. This paper discusses some of the complexities involved in diagnosing individuals affected by prenatal alcohol exposure, provides a review of the neurocognitive and neurobehavioral deficits commonly seen in this population, and examines how such deficits may manifest during different developmental periods across the life span. Additionally, strategies for assessing these deficits are described, and specific measures that are appropriate for alcohol-exposed individuals are presented. The challenges of working with this under-identified and underserved population are highlighted, as well as the importance of early diagnosis and intervention.
  • Article
    To provide national prevalence, patterns, and correlates of marijuana use in the past month and past 2-12 months among women of reproductive age by pregnancy status. Data from 2007-2012 National Surveys on Drug Use and Health, a cross-sectional nationally representative survey, identified pregnant (n=4,971) and non-pregnant (n=88,402) women 18-44 years of age. Women self-reported marijuana use in the past month and past 2-12 months (use in the past year, but not in the past month). Chi-square statistics and adjusted prevalence ratios were estimated using a weighting variable to account for the complex survey design and probability of sampling. Among pregnant women and non-pregnant women, respectively, 3.9% (95%CI: [3.2, 4.7]) and 7.6% (95%CI: [7.3, 7.9]) used marijuana in the past month and 7.0% (95%CI:[6.0, 8.2]) and 6.4% (95%CI:[6.2, 6.6]) used in the past 2-12 months. Among past-year marijuana users (n=17,934), use almost daily was reported by 16.2% of pregnant and 12.8% of non-pregnant women; and 18.1% of pregnant and 11.4% of non-pregnant women met criteria for abuse and/or dependence. Approximately 70% of both pregnant and non-pregnant women believe there is slight or no risk of harm from using marijuana once or twice a week. Smokers of tobacco, alcohol users, and other illicit drug users were 2-3 times more likely to use marijuana in the past-year than respective non-users, adjusting for sociodemographic characteristics. Over one in ten pregnant and non-pregnant women reported using marijuana in the past 12 months. A considerable percentage of women who used marijuana in the past year were daily users, met abuse and/or dependence criteria, and were poly-substance users. Comprehensive screening, treatment for use of multiple substances, and additional research and patient education on the possible harms of marijuana use are needed for all women of reproductive age. Copyright © 2015 Elsevier Inc. All rights reserved.
  • Article
    Les consommations importantes d’alcool pendant la grossesse sont responsables d’atteintes foetales variables connues sous le terme de syndrome d’alcoolisation foetale. La survenue d’un retard de croissance, d’une dysmorphie, de malformations non spécifiques et d’un retard mental est bien évaluée avec une relation effet dose. Le retentissement à long terme — cognitif et comportemental — des alcoolisations maternelles légères et modérées est controversé. Compte tenu de cette toxicité, tout suivi de grossesse devrait comporter des questions concernant la consommation d’alcool de la patiente. L’utilisation d’auto-questionnaires peut améliorer la sensibilité du dépistage.
  • Article
    Alcohol related harm is a global problem for public health where frequent consumption of large amounts of alcohol constitutes a serious health risk, particularly to vulnerable groups such as adolescents, pregnant women and newborns. The epidemiological study on health-lifestyle behaviour, especially alcohol consumption, was performed on a randomised group of post-partum women's health behaviour during pregnancy, covering drinking habits, was undertaken in 2010, 2011 and 2012, (n=8,237) according to the PRAMS model including effects on the foetus and newborn; women being selected from obstetric and gynaecological wards. In this Polish study, only 14% of women did not consume alcohol before becoming pregnant while 15% of women drank alcohol throughout the entire period of pregnancy. In addition, awareness of the harmful effects of alcohol consumed, especially of small amounts, before and during pregnancy is low among Polish women. It is also alarming that more than 55% of physicians who provide care for pregnant women do not discuss with them the harmful effect of alcohol on the organism of the mother and foetus, whereas over 2% of doctors even recommend the consumption of alcohol in pregnancy. With reference to the Barker's Foetal Origin of Diseases Hypothesis, the authors suggest such alcohol drinking behaviour of women during their reproductive ages and while pregnant may exert negative health effects on offspring, mainly in the form of susceptibility to contracting chronic diseases. Such findings pose a risk to future generations in Poland and require remedial/educational action targeted on health care professionals and public like.
  • Article
    Our goal was to measure the pregnancy-related reduction in the prevalence of reported binge drinking (>/=5 alcoholic drinks per occasion) and to characterize binge drinkers among pregnant and nonpregnant women aged 18-44 years, in the United States, 1991-1995. We used the Behavioral Risk Factor Surveillance System data from 46 states. We used the prevalence rate ratio between pregnant and nonpregnant women to determine the magnitude of the reduction in reported binge drinking and multiple logistic regression models to identify characteristics associated with binge drinking. Between 1991 and 1995, the prevalence of binge drinking among pregnant women increased significantly from 0.7% (95% confidence interval 0.2-0.9) to 2.9% (95% confidence interval 2.2-3.6), whereas among nonpregnant women the prevalence changed little (11.3% vs 11.2%). Over the study period pregnant women were one fifth (prevalence rate ratio 0.2, 95% confidence interval 0.1-0.2) as likely as nonpregnant women to binge drink. Among various population subgroups of women, pregnancy-related reduction in binge drinking was smallest among black women and largest among women aged </=30 years and among those who had quit smoking. Among pregnant women binge drinking was independently associated with being unmarried, being employed, and current smoking. Among nonpregnant women binge drinking was independently associated with age </=30 years, nonblack race, college level education, being unmarried, being employed or a student, and current smoking. Clinicians serving women of childbearing age need to be aware of the recent rise in reported binge drinking during pregnancy, as well as the known risk factors for binge drinking.
  • Substance abuse in pregnancy American College of Obstetricians and Gynecologists
    • American College
    American College of Obstetricians and Gynecologists. Substance abuse in pregnancy. ACOG technical bulletin no. 195. Washington (DC): American College of Obstetricians and Gynecologists, 1994.
  • Reports on threshold level for fetal alcohol exposure using data from 2 longitudinal studies (A. P. Streissguth et al; see PA, Vol 71:3676 and J. L. Jacobson; see PA, Vol 80:41734) on prenatal alcohol exposure and neurobehavioral development in humans. Dose–response relationships for drinking during pregnancy are described, alternative approaches for determining threshold levels are suggested, and data on the thresholds found for neurobehavioral outcomes are reviewed. Findings suggest that the neurobehavioral effect threshold in humans is 7–28 standard drinks per wk, as measured prior to pregnancy recognition or at mid pregnancy. Fewer than 7 standard drinks per week appeared to have no neurobehavioral effect. It is suggested that because human threshold values are based on average group effects, one cannot infer a defined exposure threshold as individual tolerance, both of the mother and the fetus, can differ greatly from average group results. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
  • Article
    Heavy maternal alcohol intake is a major perinatal risk but, unfortunately, is difficult for obstetricians and gynecologists to detect. To develop a brief questionnaire appropriate for office detection of "risk-drinking", that is, alcohol intake potentially sufficient to damage the fetus, defined here as ≥1 ounce of absolute alcohol per day, we obtained a quantitative drinking history at the first prenatal visit from 971 consecutive gravid women who admitted ever having drunk alcohol. In addition, we administered the 25-question Michigan Alcoholism Screening Test and the four CAGE questions (C = cut down, A = annoyed, G = guilt, E = eye opener), a screening test previously unstudied in pregnancy, and sought evidence of tolerance to the inebriating effect of alcohol, a question which does not appear to trigger psychologic denial. The patient was considered tolerant if it took >2 drinks to make her feel "high". Among 42 (4.3%) risk-drinkers and 929 women who did not report drinking at risk levels, four questions were found to contribute to reliably differentiating risk-drinkers from non-risk-drinkers (R2 = 14.6%, p < 0.0001). The probability of risk-drinking increased from 1.5% for those responding negatively to 62.7% for those responding positively to all four questions (T = tolerance, A = annoyed, C = cut down, E = eye-opener; odds ratio = 109X). A simple scoring scheme (2 points for T and 1 each for A, C, or E, with a total score of ≥2 considered positive) correctly identified 69% of the risk-drinkers (sensitivity) with a positive predictive value of 23%). The T-ACE questions take about 1 minute to ask and represent the first validated sensitive screen for risk-drinking appropriate for routine use in obstetric-gynecologic practice. If validated in further samples, broad application might contribute to better risk identification, secondary prevention efforts, and improved pregnancy outcomes for offspring at risk from heavy prenatal alcohol exposure.
  • Article
    Factors predisposing, enabling, and reinforcing physicians who provide preventive care and educate their patients about lifestyle changes have been identified in various recent studies. The organization of these findings within a framework for planning educational and behavioral change interventions suggests a series of learning principles that can be applied with greater effect than the standard continuing education format.
  • Article
    Historical reports indicate that the observation of an adverse effect on the fetus of chronic maternal alcoholism is not new. Three additional cases of the fetal alcohol syndrome have been recognised in two newborn infants and a 7-month-old baby. The immutable nature of the prenatal-onset growth deficiency was further confirmed. The first necropsy performed on a patient with fetal alcohol syndrome disclosed serious dysmorphogenesis of the brain, which may be responsible for some of the functional abnormalities and the joint malposition seen in this syndrome.
  • Article
    The CAGE questionnaire, a new brief alcoholism screening test, was administered to all patients (N = 366; 39% alcoholic) admitted to psychiatric service over a one year period. The authors indicate that the CAGE questionnaire is not a sensitive alcoholism detector if a four item positive response is the criterion; however, if a two or three item criterion is used, it becomes a viable rapid alcoholism screening technique for large groups.
  • Article
    The Michigan Alcoholism Screening Test (MAST), devised to provide a consistent, quantifiable, structured interview instrument to detect alcoholism, consists of 25 questions that can be rapidly administered. Five groups were given the MAST: hospitalized alcoholics, a control group, persons convicted of drunk driving, persons convicted of drunk and disorderly behavior, and drivers whose licenses were under review. The validity of the MAST was assessed by searching the records of legal, social, and medical agencies and reviewing the subjects' driving and criminal records. The MAST responses of 15 subjects who were found to be alcoholic in the record search were analyzed to determine where the screening failures had occurred. Recommendations are made for reducing the number of such "falsė negatives."
  • Article
    Full-text available
    To determine the knowledge, clinical experience and perceived needs for resource materials of Saskatchewan physicians in regard to fetal alcohol syndrome (FAS) and alcohol-related birth defects. Mailed survey. Saskatchewan. All 48 pediatricians and half (394) of the family physicians (FPs) and general practitioners (GPs) practising in Saskatchewan received a questionnaire. The numbers of physicians who completed it were 24 and 249 respectively. The pediatricians were more likely than the other physicians to be aware of FAS and to have diagnosed at least one case of FAS. Among the FPs and GPs, the year of graduation from medical school was a significant factor in their knowledge of FAS and their diagnostic practices. Those who graduated before 1974, the year FAS was first described in the medical literature, were less likely than the more recent graduates to be aware of FAS and to ask their patients about alcohol use during pregnancy but were more likely to feel comfortable discussing alcohol-related issues in families. All of the groups reported a need for more information about FAS and for resources on alcohol-related issues in general. Saskatchewan physicians are aware of FAS but have expressed a need for more information about FAS, particularly for parents, as well as physician training materials and information about where to refer patients with FAS and parents with alcohol-related problems.
  • Article
    The efficacy of alcohol screening questionnaires, the TWEAK, TACE, NET, MAST, and CAGE, in detecting periconceptional riskdrinking, 1 oz absolute alcohol/day, was investigated in 4743 African-American women attending an inner-city prenatal clinic who had reported ever drinking. Sensitivity, specificity, positive predictive value, efficiency, follow-up rates, and receiver operating characteristics of the questionnaires were examined to compare the overall effectiveness of the questionnaires and their performance at cutpoints defining positive scores ranging from 1 to 3. Relatively little difference between TWEAK, T-ACE, and MAST was seen in the receiver operating characteristic accuracy indices; NET and CAGE lagged behind. Sensitivity/specificity scores for the two questionnaires most sensitive at cut-point 1 were TWEAK (87/72) and T-ACE (83/75). At cut-point 2, sensitivity was optimized with respect to specificity; TWEAK (79/83) was significantly more sensitive than T-ACE (70/85; p = 0.002). At cut-point 3, the two most sensitive tests were MAST (61/92) and TWEAK (59/94). In general, measures of merit were not greatly affected by the time between conception and the administration of the screens. Screening was most sensitive for women interviewed during the first 15 weeks of pregnancy; riskdrinkers tended to delay entry into prenatal care, increasing positive predictive values associated with screening later in pregnancy. This study confirms the utility, when screening for risk-drinking during pregnancy, of brief questionnaires that assess alcohol intake indirectly by asking women about their tolerance to alcohol's effects, psychological consequences of drinking, and significant others' concern about their drinking. It validates T-ACE and provides preliminary data indicating that TWEAK may outperform T-ACE.
  • Article
    To determine the level and types of primary and preventive care services delivered by obstetrician-gynecologists. A self-administered questionnaire was mailed to a random sample of 1250 obstetrician-gynecologists practicing in the United States. The response rate was 71%. Fifty-three percent of the respondents indicated that they provide primary and preventive care during more than half of their practice time. Although obstetrician-gynecologists provide a wide range of preventive services, the proportion of doctors providing any specific service varies. Whereas virtually all (92% or more) obstetrician-gynecologists provide or order blood pressure screening, breast examinations, mammography, and Papanicolaou tests, only six of ten report regular cholesterol screening for most of their patients. A higher percentage of female obstetrician-gynecologists, who are on average younger than their male counterparts, report that they provide primary preventive services to most of their patients. The majority of obstetrician-gynecologists provide a wide range of primary and preventive care services to their patients, although there is variability in the proportion of doctors providing any specific service to most (60% or more) of their patients.
  • Article
    This article presents data on the awareness of the alcohol beverage warning label among a sample of 5,169 inner city African-American gravidas seeking prenatal care. While the label law was implemented in November 1989, a significant increase in knowledge of the label did not occur until March 1990. Women who predominantly consumed wine coolers and beer, and those under age 30 were more likely to know about the label than their counterparts.
  • Article
    The consequences of fetal alcohol exposure are far-reaching and preventable. Health care providers are uniquely positioned to promote alcohol-free pregnancy, yet an array of factors inhibit routine screening, counseling, and referral. This descriptive, qualitative study explored experiences and perceived barriers related to prenatal screening for alcohol use. The study included eight focus groups (71 participants) and 41 key informant interviews with health care professionals representing a mix of disciplines. Nearly 40% of the providers were physicians who regularly encounter women in their practices. While most providers ask about alcohol use, few probe in depth or follow up. The findings should alert program planners and medical educators to strengthen their preventive medical and public health practices.
  • Article
    Project TrEAT (Trial for Early Alcohol Treatment) was designed to test the efficacy of brief physician advice in reducing alcohol use and health care utilization in problem drinkers. Randomized controlled clinical trial with 12-month follow-up. A total of 17 community-based primary care practices (64 physicians) located in 10 Wisconsin counties. Of the 17695 patients screened for problem drinking, 482 men and 292 women met inclusion criteria and were randomized into a control (n=382) or an experimental (n=392) group. A total of 723 subjects (93%) participated in the 12-month follow-up procedures. The intervention consisted of two 10- to 15-minute counseling visits delivered by physicians using a scripted workbook that included advice, education, and contracting information. Alcohol use measures, emergency department visits, and hospital days. There were no significant differences between groups at baseline on alcohol use, age, socioeconomic status, smoking status, rates of depression or anxiety, frequency of conduct disorders, lifetime drug use, or health care utilization. At the time of the 12-month follow-up, there were significant reductions in 7-day alcohol use (mean number of drinks in previous 7 days decreased from 19.1 at baseline to 11.5 at 12 months for the experimental group vs 18.9 at baseline to 15.5 at 12 months for controls; t=4.33; P<.001), episodes of binge drinking (mean number of binge drinking episodes during previous 30 days decreased from 5.7 at baseline to 3.1 at 12 months for the experimental group vs 5.3 at baseline to 4.2 at 12 months for controls; t=2.81; P<.001), and frequency of excessive drinking (percentage drinking excessively in previous 7 days decreased from 47.5% at baseline to 17.8% at 12 months for the experimental group vs 48.1% at baseline to 32.5% at 12 months for controls; t=4.53; P<.001). The chi2 test of independence revealed a significant relationship between group status and length of hospitalization over the study period for men (P<.01). This study provides the first direct evidence that physician intervention with problem drinkers decreases alcohol use and health resource utilization in the US health care system.
  • Article
    Full-text available
    To determine the association between light-to-moderate prenatal alcohol exposure and congenital renal anomalies. Data from the population-based Atlanta Birth Defects Case-Control Study were used to examine the association between selected renal anomalies and self-reported maternal alcohol consumption during the period from 1 month before through 3 months after conception. Case infants were ascertained by a population-based birth defects registry with active case ascertainment; the case group consisted of 158 infants, born during 1968 through 1980 to metropolitan Atlanta residents, in whom these renal anomalies had been diagnosed. Two control groups were used. One had 3029 infants without birth defects, and the other had 4633 infants with birth defects exclusive of the urinary tract who were born during the same period. Overall, there was a moderate association between renal anomalies and moderate prenatal alcohol exposure (odds ratio, 1.5; 95% confidence interval, 1.0 to 2.3). When the renal anomalies were subclassified, moderate prenatal alcohol exposure was significantly associated only with renal agenesis or hypoplasia (odds ratio, 2.5; 95% confidence interval, 1.2 to 5.1), and within this group only infants with bilateral defects and other major anomalies in addition to renal agenesis or hypoplasia had significantly elevated risks. There were no significant associations between reported light consumption and any category of the selected renal anomalies. No conclusions could be reached for reported heavy consumption because of sparse data. Adjustments for potential confounding factors did not alter these results. This study suggests that moderate alcohol consumption during pregnancy may increase a woman's risk of giving birth to a child with renal agenesis or hypoplasia.
  • Article
    Maternal alcoholism is known to have adverse effects on reproduction and fetal development, but the effects of moderate consumption remain controversial. In a previous case-control study, we found a doubled risk of spontaneous abortion with an average consumption of seven or more drinks per week during the first trimester. To confirm this finding while avoiding potential biases from the case-control design, we examined moderate alcohol consumption in a prospective cohort study of over 5,000 pregnant women. An interview in the first trimester asked about alcohol consumption during the week before interview ("during the first trimester") and before pregnancy. We found an increased risk of spontaneous abortion in women who drank more than three drinks per week during the first trimester, with an adjusted odds ratio (OR) of 2.3 [95% confidence interval (CI) = 1.1-4.5]. The increased risk associated with this moderate alcohol consumption may be higher in first than in second trimester abortions, and it is even higher in the first 10 weeks (OR = 3.8; 95% CI = 1.7-8.7), based on small numbers. Consumption of alcohol before pregnancy was not strongly associated with spontaneous abortion.
  • Article
    Heavy drinking during pregnancy is an established risk factor for fetal alcohol syndrome and other adverse perinatal outcomes. However, there is still debate as to the effects of low-to-moderate drinking during pregnancy. This prospective investigation was based on 2714 singleton live births at Yale-New Haven Hospital during 1988-1992. Alcohol drinking during pregnancy was evaluated with respect to intrauterine growth retardation (IUGR), preterm delivery, and low birthweight. Mild drinking, defined as > 0.10-0.25 oz of absolute alcohol per day, during the first month of pregnancy was associated with a protective effect on IUGR (OR, 0.39; 95% confidence interval (CI), 0.20-0.76). Overall, drinking during month 1 of pregnancy suggested a curvilinear effect on growth retardation, with consumption of > 1.00 oz of absolute alcohol per day showing increased risk. Drinking during month 7 was associated with a uniform increase in the odds of preterm delivery; the ORs were 2.88 (95% CI, 1.64-5.05) for light drinking and 2.96 (95% CI, 1.32-6.67) for mild-to-moderate alcohol consumption. Differences in the risk estimates for IUGR and preterm delivery may indicate etiological differences that warrant further investigation of these outcomes and critical periods of exposure. Low birthweight is not a useful neonatal outcome for this exposure because it is a heterogeneous mix of preterm delivery and IUGR. Despite the observed protective effects of mild drinking on IUGR, the increased risk of preterm delivery with alcohol use supports a policy of abstinence during pregnancy.
  • Article
    To examine trends in alcohol use among pregnant women in the United States and to characterize pregnant women who use alcohol, with an emphasis on frequent use (at least five drinks per occasion or at least seven drinks per week). We used the Behavioral Risk Factor Surveillance System data from 1988 through 1995 to obtain the percentage of pregnant women who used alcohol. We used multiple logistic models to identify subgroups of pregnant women who are at increased risk for alcohol use. Overall, 14.6% (869 of 5983) of pregnant women consumed alcohol and 2.1% (133 of 5983) consumed alcohol frequently. Among pregnant women, alcohol use decreased from 22.5% (95% confidence interval [CI] 20.8, 23.9) in 1988 to 9.5% (95% CI 7.9, 11.8) in 1992 and then increased to 15.3% (95% CI 13.1, 17.2) by 1995. Among pregnant women, frequent alcohol use decreased from 3.9% (95% CI 2.4, 5.2) in 1988 to 0.9% (95% CI 0.4, 1.6) in 1991 and then increased to 3.5% (95% CI 2.0, 5.1) by 1995. Pregnant women who were at high risk for alcohol use were college educated, unmarried, employed, or students, had annual household incomes of more than $50,000, or were smokers. Pregnant women who were at high risk for frequent alcohol use were more likely to be unmarried, or smokers. The increasing prevalence of alcohol use among pregnant women calls for increased ascertainment of alcohol use among preconceptional and pregnant women. Brief interventions by clinicians, increased referral to alcohol treatment programs, and increased use of contraception by women of reproductive age who are problem drinkers should be considered as means of preventing alcohol-exposed pregnancies.
  • Article
    Pediatricians, obstetricians, and family practice physicians in Michigan were surveyed by mail for their knowledge and opinions about Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (FAE). Physicians said that about 67% of their patients raised questions about drinking during pregnancy but only 2% specifically referred to FAS or FAE. Most physicians were uncertain about whether their colleagues were sufficiently aware of FAS, whether FAS could be diagnosed at birth, or if physicians were acquainted with the syndrome's major criteria. However, most believed FAS was not being overdiagnosed and believed that making a diagnosis of FAS at birth could lead to improved treatment of an affected child. Physicians also believed that physician counseling was a more effective way of reducing the incidence of FAS/FAE than warning labels. Forty-one percent of the physicians placed the threshold for FAS at one to three drinks per day and 38% placed the threshold at one or fewer drinks a day. Thirty-five percent placed the estimated incidence of FAS at 1 to 2 per 1000 in the United States. We conclude that physicians are in relative agreement about the effects of drinking during pregnancy and the value of physician counseling but are misguided as to what constitutes a true risk level of drinking as far as the etiology of FAS is concerned.
  • Article
    To investigate whether periconceptional maternal alcohol consumption increased the risk of delivering infants with orofacial cleft phenotypes. Data were derived from a large population-based case control study of fetuses and infants among a cohort of California births from 1987 to 1989 (n = 548,844). Information concerning alcohol consumption was obtained by telephone interviews with mothers of 731 infants (84.7% of eligible) with orofacial clefts and of 734 (78.2%) infants in a nonmalformed control group. Thirty-nine percent of mothers in the case group and 42% of mothers in the control group reported that they consumed alcohol during the period 1 month before through 3 months after conception. Relative to nonconsumers, women who reported alcohol consumption (<weekly, weekly, or daily) were not at substantially increased risk of delivering infants with any cleft phenotype. However, for women who reported weekly or more frequent episodes of consuming >/=5 drinks per drinking occasion compared with those who did not, we observed increased risks for isolated (no other major congenital anomaly) cleft lip with or without cleft palate, odds ratio = 3.4 (95% confidence interval, 1.1 to 9.7); multiple cleft lip with or without cleft palate, odds ratio = 4.6 (1. 2 to 18.8); and "known syndrome" clefts, odds ratio = 6.9 (1.9 to 28. 6). Adjustment for maternal cigarette smoking, race, education, or vitamin use did not substantially change observed risks. We observed a lack of increased risks of clefts for relatively low quantities of maternal alcohol consumption and increased risks of clefts for higher quantities of maternal alcohol consumption.