R. Louise Floyd

Alcohol use prior to pregnancy recognition.

BACKGROUND Frequent alcohol use during the first 8 weeks of pregnancy can result in spontaneous abortion and dysmorphologic changes in the developing organ systems of the embryo, including the heart, kidneys, and brain. However, few population-based studies are available that describe the prevalence of frequent drinking (6 or more drinks per week) among women prior to and during early pregnancy (the periconceptional period), and the sociodemographic and behavioral factors that characterize these women. Such knowledge is fundamental to the design of targeted interventions for the prevention of fetal alcohol syndrome (FAS) and other prenatal alcohol-related disorders. METHODS This cross-sectional study used survey data collected by the National Center for Health Statistics as part of the 1988 National Maternal and Infant Health Survey (NMIHS). Weighted prevalence estimates were calculated using SUDAAN, and multivariate analyses were used to determine risk factors for frequent drinking. RESULTS Forty-five percent of all women surveyed reported consuming alcohol during the 3 months before finding out they were pregnant, and 5% reported consuming 6 or more drinks per week. Sixty percent of women who reported alcohol consumption also reported that they did not learn they were pregnant until after the fourth week of gestation. Risk factors for frequent drinking during the periconceptional period included 1 or more of the following: being unmarried, being a smoker, being white non-Hispanic, being 25 years of age or older, or being college educated. CONCLUSIONS Half of all pregnant women in this study drank alcohol during the 3 months preceding pregnancy recognition, with 1 in 20 drinking at moderate to heavy levels. The majority did not know they were pregnant until after the fourth week of pregnancy, and many did not know until after the 6th week. Alcohol is a teratogen capable of producing a number of adverse reproductive and infant outcomes. Public health measures needed to reduce these potentially harmful exposures include alcohol assessment, education, and counseling for women of childbearing age, with referral sources for problem drinking, and family planning services for pregnancy postponement until problem drinking is resolved.

Comparison of binge drinking among pregnant and nonpregnant women, United States, 1991-1995

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.

PREVENTION OF FETAL ALCOHOL SPECTRUM DISORDERS

Alcohol use among women of childbearing age is a leading, preventable cause of birth defects and developmental disabilities in the United States. Although most women reduce their alcohol use upon pregnancy recognition, some women report drinking during pregnancy and others may continue to drink prior to realizing they are pregnant. These findings emphasize the need for effective prevention strategies for both pregnant and nonpregnant women who might be at risk for an alcohol-exposed pregnancy (AEP). This report reviews evidence supporting alcohol screening and brief intervention as an effective approach to reducing problem drinking and AEPs that can lead to fetal alcohol spectrum disorders. In addition, this article highlights a recent report of the National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect that describes effective interventions to reduce alcohol use and AEPs, and outlines recommendations on promoting and improving these strategies. Utilizing evidence-based alcohol screening tools and brief counseling for women at risk for an AEP and other effective population-based strategies can help achieve future alcohol-free pregnancies.

The clinical content of preconception care: alcohol, tobacco, and illicit drug exposures

Substance abuse poses significant health risks to childbearing-aged women in the United States and, for those who become pregnant, to their children. Alcohol is the most prevalent substance consumed by childbearing-aged women, followed by tobacco, and a variety of illicit drugs. Substance use in the preconception period predicts substance use during the prenatal period. Evidence-based methods for screening and intervening on harmful consumption patterns of these substances have been developed and are recommended for use in primary care settings for women who are pregnant, planning a pregnancy, or at risk for becoming pregnant. This report describes the scope of substance abuse in the target population and provides recommendations from the Clinical Working Group of the Select Panel on Preconception Care, Centers for Disease Control and Prevention, for addressing alcohol, tobacco, and illicit drug use among childbearing-aged women.

Patterns and Average Volume of Alcohol Use Among Women of Childbearing Age

Objectives: Maternal alcohol use is a leading preventable cause of neurobehavioral and developmental abnormalities in children. This study examines the patterns and average volume of alcohol use among U.S. women of childbearing age in order to identify subgroups of high-risk women for selective intervention. Methods: A sample of 188,290 women aged 18–44 years participated in the Centers for Disease Controls and Prevention (CDC)’s Behavioral Risk Factor Surveillance System (BRFSS) survey during the period of 2001–2003. Reported alcohol use patterns and average volume were examined for pregnant and nonpregnant women. Efforts were made to evaluate and characterize women who practiced various levels of binge drinking. Results: The results showed that approximately 2% of pregnant women and 13% of nonpregnant women in the United States engaged in binge drinking during the period of 2001–2003. Among the estimated average of 6.7 million women of childbearing age overall who engaged in binge drinking during the period, approximately 28.5% women also reported consuming an average of 5 drinks or more on typical drinking days, or about 21.4% women consumed at least 45 drinks on average in a month. Larger proportions of binge drinkers with high usual quantity of consumption were found among women of younger ages (18–24 years) or current smokers. Conclusions: Future prevention efforts should include strategies that combine health messages and encourage women of childbearing age, with particular emphasis on women 18–24 years, to avoid alcohol and tobacco use, and take multivitamins and folic acid daily for better pregnancy outcomes. Other efforts must also include broad-based implementation of screening and brief intervention for alcohol misuse in primary and women’s health care settings.

Observations from the CDC: Preventing Alcohol-Exposed Pregnancies among Women of Childbearing Age: The Necessity of a Preconceptional Approach

FETAL ALCOHOL SYNDROME (FAS) is regarded as one of the leading preventable causes of mental retardation in the United States.1 Although FAS is found primarily among children whose mothers were chronic, heavy alcohol consumers during pregnancy,2 ongoing research has documented a spectrum of adverse reproductive, infant, and child health outcomes resulting from prenatal alcohol exposure, some starting at thresholds as low as four drinks per week.3,4 Although surveys show that 9 of 10 women are aware of the adverse reproductive health consequences of drinking during pregnancy,1 in 1995 approximately 175,000 pregnancies were exposed to levels of alcohol known to carry increased risk for adverse pregnancy and infant outcomes.5 The adverse effects of prenatal alcohol exposure extend throughout pregnancy but are particularly deleterious to developing organ systems during the early part of the first trimester.6,7 Therefore, prevention of these adverse effects requires an approach that addresses alcohol use behaviors during the early weeks of pregnancy. As pregnancy recognition may not occur until the sixth week in many women, the maximum prevention benefit can be gained only if we find and intervene with women at greatest risk for an alcoholexposed pregnancy before they become pregnant. A prerequisite to this prevention effort is to develop a thorough understanding of the prevalence, patterns, and risk factors associated with frequent alcohol use among women of childbearing age—those who are pregnant and those who will become pregnant.

Report from the CDC. Physician and allied health professionals' training and fetal alcohol syndrome.

Maternal prenatal alcohol use is one of the leading preventable causes of birth defects and developmental disabilities. On the severe end of the spectrum of conditions related to drinking during pregnancy is fetal alcohol syndrome (FAS). Physicians and other health practitioners play a critical role in diagnosing FAS and in screening women of childbearing age for alcohol use during pregnancy. The Fetal Alcohol Syndrome Prevention Team at CDCs National Center on Birth Defects and Developmental Disabilities awarded funds to four medical school partners (Meharry and Morehouse Medical Colleges, St. Louis University, the University of Medicine and Dentistry of New Jersey, and the University of California at Los Angeles) to develop FAS regional training centers (RTCs). The RTCs are developing, implementing, evaluating, and disseminating educational curricula for medical and allied health students and practitioners that incorporate evidence-based diagnostic guidelines for FAS and other prenatal alcohol-related disorders.

A National Action Plan for Promoting Preconception Health and Health Care in the United States (2012–2014)

Preconception health and health care (PCHHC) has gained increasing popularity as a key prevention strategy for improving outcomes for women and infants, both domestically and internationally. The Action Plan for the National Initiative on Preconception Health and Health Care: A Report of the PCHHC Steering Committee (2012-2014) provides a model that states, communities, public, and private organizations can use to help guide strategic planning for promoting preconception care projects. Since 2005, a national public-private PCHHC initiative has worked to create and implement recommendations on this topic. Leadership and funding from the Centers for Disease Control and Prevention combined with the commitment of maternal and child health leaders across the country brought together key partners from the public and private sector to provide expertise and technical assistance to develop an updated national action plan for the PCHHC Initiative. Key activities for this process included the identification of goals, objectives, strategies, actions, and anticipated timelines for the five workgroups that were established as part of the original PCHHC Initiative. These are further described in the action plan. To assist other groups doing similar work, this article discusses the approach members of the PCHHC Initiative took to convene local, state, and national leaders to enhance the implementation of preconception care nationally through accomplishments, lessons learned, and projections for future directions.

Characteristics and behaviors of mothers who have a child with fetal alcohol syndrome.

Fetal alcohol syndrome (FAS) is a leading cause of birth defects and developmental disabilities. The objective of this study was to identify the characteristics and behaviors of mothers of children with FAS in the United States using population-based data from the FAS Surveillance Network (FASSNet). FASSNet used a multiple source methodology that identified FAS cases through passive reporting and active review of records from hospitals, specialty clinics, private physicians, early intervention programs, Medicaid, birth certificates and other vital records, birth defects surveillance programs, and hospital discharge data. The surveillance included children born during January 1, 1995-December 31, 1997. In the four states included in our analysis - Arizona, New York, Alaska, and Colorado - there were 257 confirmed cases and 96 probable cases for a total of 353 FAS cases. Compared to all mothers in the states where surveillance occurred, mothers of children with FAS were significantly more likely to be older, American Indians/Alaska Natives, Black, not Hispanic, unmarried, unemployed, and without prenatal care, to smoke during pregnancy, to have a lower educational level, and to have more live born children. A significant proportion of mothers (9-29%) had another child with suspected alcohol effects. Compared to all US mothers, they were also significantly more likely to be on public assistance, to be on Medicaid at their childs birth, to have received treatment for alcohol abuse, to have confirmed alcoholism, to have used marijuana or cocaine during pregnancy, to have their baby screen positive for alcohol or drugs at birth, to have had an induced abortion, to have had a history of mental illness, to have been involved in binge drinking during pregnancy, and to have drunk heavily (7 days/week) during pregnancy. These findings suggest that it is possible to identify women who are at high risk of having a child with FAS and target these women for interventions.

Neonatal mortality in normal birth weight babies: Does the level of hospital care make a difference?

Although neonatal intensive care for low birth weight infants has been extensively studied, few researchers have looked at the impact of the level of care at the delivery hospital for infants weighing greater than 2500 gm. Using linked birth-death records from Georgia for 1979 to 1982, we examined the effect that the level of care available at the hospital of delivery had on neonatal mortality in infants weighing 2500 gm and above. We used a risk scoring system designed for use with vital records to determine prepartum risk and the presence or absence of a complication of labor as indicated on the birth certificate to determine intrapartum risk. We found that women with a high prepartum risk score had increased neonatal mortality at level 1 hospitals. Women who developed a complication of labor, regardless of their prepartum risk status, had the highest neonatal mortality rates when they delivered at level 1 hospitals. We suggest prenatal risk assessment for all women and referral of high risk women to level 2 or 3 hospitals for delivery even at term.