Assessing maternal alcohol use

The timing, frequency and quantity of prenatal alcohol exposure are linked to the pattern and severity of fetal outcomes. Brain growth and development occur throughout pregnancy hence adverse cognitive, behavioural and neurodevelopmental outcomes may result from exposure at any time during pregnancy and may occur in the absence of facial anomalies or structural central nervous system abnormalities.

Factors that contribute to women drinking alcohol during pregnancy

There are many factors that contribute to women drinking alcohol during pregnancy:

lack of knowledge about the effects of alcohol on the fetus
lack of convincing evidence that the occasional drink is harmful
having a partner or friend who drinks
opinions from family and friends who drank in pregnancy with apparently healthy children
peer pressure, particularly about drinking on special occassions such as birthdays, weddings, new years eve
lack of support from partner, friends and family
living in a family or community tolerant of heavy drinking
social isolation & living in remote communities
poverty
unemployment
stress, domestic violence, loneliness which may result in self-medicating
women who have FASD themselves

While poverty and unemployment may be contributing to drinking in some populations, Australian research has found that in mainstream public antenatal care, higher income and tertiary educated women were 2-4 times more likely to drink alcohol throughout pregnancy than women with only secondary school education. [References]

The risk of harm from alcohol is hard to predict and is different for everybody. This is because factors such as the mother’s age, her general health and any medical conditions she may have, her levels of stress, other drug use and smoking, and even her body composition can influence how alcohol is metabolised and therefore the risk of harm to the developing baby. The genetic makeup of mother and baby can also make a difference in this process.

Health professionals' role

Health professionals have a role to contribute to making a difference with women around the issue of alcohol consumption before and during pregnancy. They should:

have knowledge of the Australian Guidelines on reducing health risks from drinking alcohol
give advice consistent with these guidelines
be cognisant of the high level of unplanned pregnancies (30% - 47%) [References]
ask all pregnant women about their alcohol use
have an understanding of the support needs of pregnant women who have substance use problems
have an understanding of the support needs of pregnant women with FASD who have substance use problems

Some questions to begin history taking

Was the pregnancy planned?
When did you realise you were pregnant?
Were you drinking alcohol before you knew you were pregnant?
Did you change your alcohol consumption on confirmation of pregnancy?
Were there any special occasions or life events (eg birthday, wedding, New Year’s Eve, death in the family) during pregnancy when alcohol was consumed at a high level?

More information is provided in Section A in the Australian Guide to the diagnosis of FASD.

General Practitioners, obstetricians and midwives play an important role in talking to women about having a healthy pregnancy. They should take any opportunity to ask and advise about alcohol use when planning a pregnancy and during pregnancy. Some women may find it difficult to stop drinking and will require referral to services that assist with addiction problems.

Health professionals can help address the issue of alcohol use for women planning a pregnancy and during pregnancy.

Ask about their alcohol use
Assess and record the level of risk of the alcohol consumption
Advise women that alcohol use may: harm the developing fetus; no alcohol is the safest option; alcohol reaches concentrations in the fetal circulation are as high as the mothers; and stopping drinking at any time during pregnancy reduces the risk to the fetus
Assist women to stop or reduce alcohol consumption through positive reinforcement; talking about the consequences of alcohol exposure to the fetus; and conducting brief interventions with the aim of supporting the woman to abstain, and where this is not possible, to reduce alcohol use
Arrange for further support by planning additional consultations or referral to specialist services and support groups

AUDIT-C

When detailed information on maternal alcohol use is available, consumption during pregnancy should be assessed using the Alcohol Use Disorders Identification Test – Consumption (AUDIT-C) questions. The AUDIT-C questions provide a standardised method for assessment of maternal alcohol use and are based on a validated sex-specific version of the instrument.

Information on the definition of a standard drink for different types of alcoholic drinks should be provided prior to asking questions about alcohol use. Appendix B of the Australian Guide to the diagnosis of FASD shows standard drink sizes for commonly consumed drinks.

A non-judgemental approach is important when taking a history of alcohol consumption in pregnancy. Questions about alcohol should be asked in the context of optimising outcomes in pregnancy, together with other questions such as smoking, diet, stress and exercise.

More information on using the AUDIT-C is available here.

What is an alcohol use disorder

Alcohol use disorder is usually seen as problematic drinking that results in a range of situations such as:

drinking more or for a longer period of time
spending a lot of time recovering from the after effects of alcohol
craving or thinking about wanting to drink
continuing to drink even though it is causing problems with family members, friends, education or work
continuing to drink even when it is causing health problems such as trouble sleeping, heart palpitations, anxiety, memory loss
putting yourself and others at risk by drinking and driving; drinking and operating machinery; drinking and engaging in unsafe sex

Alcohol use disorders can range from mild to severe, with the most severe being alcohol dependence.

What is needed?

There is a lack of highly trained professionals and appropriate services for pregnant women with alcohol use problems. Research conducted at the National Drug and Alcohol Research Centre (NDARC) confirms:

all pregnant women who screen positively for alcohol-use disorders should be offered access to treatment that matches the severity of the disorder. Treatment may include inpatient admission for detoxification if necessary.
all pregnant women who are alcohol dependent should be offered extended hospitalisation after their child’s birth for additional help and support. Women and children should also be followed-up through the child’s formative years to provide assistance with healthcare, social services, housing and parenting.
treatment of pregnant women who are alcohol dependent should be undertaken by a multidisciplinary team. This includes alcohol and other drug services, obstetric care and a GP.

Working with women with alcohol use disorders

Health professionals working with women with alcohol use disorders need to be FASD informed when providing treatment and support as some of their clients may also have FASD. The following list includes some key Australian and Canadian publications.

National Drug and Alcohol Research Centre

It’s time to have the conversation: Understanding the treatment needs of women who are pregnant and alcohol dependent

A Guide for Health Care Professionals Supporting Pregnant Women who use Alcohol or Other Drugs

Series of videos to help health care professionals support pregnant women who use alcohol or other drugs. These videos accompany the Guide for health professionals (above)

Supporting pregnant women who use alcohol or other drugs: a review of the evidence

NSW Health

NSW Guidelines for the management of substance use during pregnancy birth and postnatal period

Australian Government Department of Health

Referrals - information for women and health professionals

Homeless Hub (Canada)

Substance using women with FASD and FASD prevention: A literature review of promising approaches in substance use treatment and care for women with FASD

Voices of women with FASD: Promising approaches in substance use treatment and care for women with FASD