Maternal alcohol consumption is a preventable health risk that can cause harm to the fetus and cause birth defects. Articles relating to the risk factors associated with maternal alcohol consumption, prevention of the risk factors, and a discussion on fetal alcohol spectrum disorders were reviewed. Several risk factors were identified, but the most prevalent risk factors include poverty, homelessness, substance abuse by a partner, and preconception alcohol use. Several preventative measures and screenings exist to identify women at risk for alcohol consumption during pregnancy and treatment options for women in need of intervention. Alcohol consumption during pregnancy can be prevented if early screening and interventions are implemented. However, screenings are often not implemented adequately and in a timely manner because of a lack of knowledge among health care providers. Educating health care providers on the use and implementation of the screenings can identify women at risk for maternal alcohol consumption before irreversible harm to the fetus occurs.
Fetal Alcohol Spectrum Disorders (FASD) are caused by consumption of alcohol during pregnancy. According to current research, about one in 30 women are at risk for alcohol consumption during pregnancy, which can lead to preventable instances of FASD (Cannon et al., 2015). Fetal alcohol spectrum disorders include a number of more specific syndromes along this spectrum, such as: fetal alcohol syndrome (FAS), partial fetal alcohol syndrome, alcohol related neurodevelopment disorder (ARND), fetal alcohol defects, and alcohol related birth defects. Some signs and symptoms of prenatal alcohol exposure include behavioral problems, neurological problems, and memory deficits, among many others. Fetal alcohol syndrome is the most severe type of FASD and can cause mild to severe complications (Esper & Furtado, 2014).
Many risk factors are associated with alcohol consumption during pregnancy. These include homelessness, substance abuse by a partner, and preconception alcohol abuse. Alcohol use before pregnancy is the biggest risk factor for maternal alcohol consumption (Esper et al., 2014). The solution to preventing FASD is the prevention of maternal alcohol consumption. Screenings can be useful tools for identification and treatment of women at risk for alcohol consumption during pregnancy. Examples of these include, brief interventions (Lacey, 2016), TWEAK, T-ACE, 4 P’s Plus, 5 P’s Behavioral Risk Screening Tool (5 P’s), Screening, Brief Intervention, Referral to Treatment (SBIRT) (O’Brien, 2013), and motivational interviewing (Wagner, Garbers, Lang, Borgert, & Fisher, 2016).
This paper will discuss FASD, the most prevalent risk factors for alcohol consumption during pregnancy, and possible solutions for preventing maternal alcohol consumption. Recommendations for implementation of the solutions to prevent maternal alcohol consumption will also be presented.
The research for this paper was obtained by selecting relevant peer-reviewed articles through the search engines EBSCOhost and Galileo. The following search terms were used: FASD, risk factors for maternal alcohol consumption, and prevention of maternal risk factors for maternal alcohol consumption. Selected literature was limited to articles had been published within the last five years and were peer-reviewed.
Risk factors for maternal consumption
Several categories of risk factors for maternal alcohol consumption were identified. They include demographic factors, family and social factors, and psychiatric factors. According to Michael Cannon et al. (2015), in any given one-month period around two-million non-pregnant women in the United States are at risk for an alcohol exposed pregnancy (AEP) and having a child born with an FASD. Many women who consume alcohol during pregnancy often do not know they are pregnant until after the alcohol may have already affected the child (Cannon et al., 2015).
E.L Abel and J.H. Hannigan proposed a model that divides the risk factors for FASD into two categories: permissive and provocative (Esper et al., 2014). Permissive factors can include stress, additive drugs, and low socioeconomic status, among others. These factors increase the vulnerability to ethanol, which is the teratogen in alcohol that can cross the placenta and harm the fetus. Provocative factors increase the susceptibility of the fetus to ethanol. Examples of provocative risk factors include hypoxia and malnutrition. The most prevalent risk factors that put women at risk for maternal alcohol consumption are low socioeconomic status, low education level, older maternal age, poor relationship with a partner, having a partner who abuses alcohol, experiencing an increased number of stressful events, maternal cognitive impairments, family members who abuse alcohol, having previously given birth to a child with FASD, and high level of alcohol consumption before pregnancy (Cannon et al., 2015; Esper et al., 2014; Murawski et al., 2015).
Fetal alcohol spectrum disorder
Fetal alcohol syndrome is the most severe form of FASD and has characteristics that make it easier to diagnose than other forms of FASD (Murawski, Moore, Thomas & Riley, 2015). Characteristics of fetal alcohol syndrome include growth retardation, central nervous system dysfunction, and craniofacial anomalies. Craniofacial anomalies related to FAS have a specific pattern, which include a low nasal bridge, abnormalities of the ears, epicanthal folds, a thin upper lip, flat midface, short palpebral fissure, wide space between the eyes, and a smooth philtrum (Murawski et al., 2015). Diagnosis of FAS is done by identifying these craniofacial anomalies in individuals, however many people do not exhibit these characteristics despite having FAS. Those who do not meet the criteria are considered to have ARND, which is harder to diagnose because of the lack of facial abnormalities. Diagnosis of ARND requires confirmation of maternal alcohol consumption by the birth mother. Since many children with FASD are in foster care or have been adopted diagnosis of ARND is difficult (Murawski et al., 2015).
Prenatal exposure of a fetus to alcohol depends on the timing of exposure, length of exposure, prenatal nutrition, maternal age, and other substance abuse (O’Brien, 2014). For example, consuming large quantities of alcohol at a fast rate is more likely to affect that fetus than consuming it at a slower rate (O’Brien, 2014). Studies have shown that nutritional deficiencies during pregnancy can cause the fetus to become more susceptible to alcohol exposure (Murawski et al., 2015) and that an older age of the mother has been shown to increase the risk of FASD compared with those of younger age during pregnancy (Esper et al., 2014).
Prevention of maternal risk factors
Several screenings and treatments exist that can be performed to identify women at risk for an alcohol exposed pregnancy (AEP) (O’Brien, 2014) as well as to help treat those at risk. The SBIRT, 4 P’s Plus, and 5 P’s can reduce continued use of alcohol while TWEAK and T-ACE identify alcohol consumption, risky alcohol consumption, and current consumption (O’Brien, 2014). Motivational interviewing is a treatment that can promote motivation to change behaviors (Wagner et al., 2016).
The SBIRT includes brief interventions and referral to treatment. Brief interventions are short interviews with clients with hope to help the client achieve moderate alcohol consumption that is not as hazardous to the fetus. The two types of brief interventions are the very brief intervention (VBI) and the extended brief intervention (EBI) (Lacey, 2016). The VBI consists of one five to 20-minute interview that provides information and advice to clients who are not directly seeking information and advice. The EBI consists of several 20 to 30-minute interviews that are geared towards clients seeking information and advice. Referral to treatment involves referring individuals at high risk for maternal drinking to an alcohol treatment program (Lacey, 2016).
The TWEAK and T-ACE screenings are used for identifying women at risk for maternal alcohol consumption. However, they are better for identifying heavy alcohol consumption rather than current alcohol consumption. The TWEAK screening is an acronym for questions regarding tolerance (T), worry (W), eye opener (E), amnesia (A), and cut down (K) (O’Brien, 2014). Tolerance questions ask how many alcoholic beverages the individual is able to hold, worry questions ask whether the individual has friends or family that have expressed their concerns about the alcohol consumption, eye opener questions ask whether the individual needs a drink of alcohol in the morning to wake up, amnesia questions ask if the individual has done anything while consuming alcohol that she does not remember, and cut down questions ask if the individual has the urge to cut down on alcohol consumption (O’Brien, 2014). The T-ACE screening asks questions about tolerance (T), how many people have annoyed the individual about drinking (A), cut down (C), and eye opener (E) (O’Brien, 2014).
The 4 P’s and 5 P’s screening tools are used to identify pregnant women at risk for alcohol consumption, and can be used to identify current alcohol consumption and drug abuse. The 4 P’s and 5 P’s screenings ask about a history of smoking, family drug abuse, friends with drug abuse issues or who have problems with the individual’s alcohol consumption, a partner with alcohol problems, difficulty with drugs and alcohol in the past, current alcohol consumption, emotional health, relationship violence, and any positive answers to friends or family having problems with drugs or alcohol (O’Brien, 2014).
Motivational interviewing has been shown to increase the motivation of individuals to cope with their problem. Motivational interviewing can be used with both women who are pregnant or non-pregnant and males. This method incorporates open-ended questions that are client-centered to help the client identify and acknowledge that he or she has an issue with alcohol or drugs. The client controls the conversation, and decides how and when to change his or her behaviors. (Wagner et al., 2016).
According to Peggy O’Brien (2014), SBIRT is not consistently used because health care providers do not have the knowledge to implement this tool, they lack sufficient time, and they have misperceptions about women consuming alcohol. Health care providers are also concerned about not being reimbursed for screening pregnant women about their use of alcohol. To increase the use of SBIRT, performance measures were proposed, including comparing the number of pregnant women screened during their first prenatal visit and all pregnant women seen for their first prenatal visits as well as comparing pregnant women who received a brief intervention or referral to treatment and all pregnant women seen for their first prenatal visit (O’Brien, 2014). Jo Lacy (2016) discussed using brief interventions for pregnant women to help them overcome alcohol consumption during pregnancy. Brief interventions help the individual become motivated to decrease their alcohol consumption by changing their behavior (Lacy, 2016).
Andrew Wagner et al. (2016), discussed the use of SBIRT as well as motivational interviewing, but not specifically in regards to pregnant women. According to Wagner et al. (2016), individuals are motivated to overcome their alcohol consumption and are able to acknowledge that their alcohol consumption is connected with social and physical problems. Evidence-based practice suggests that patients are more engaged when the interviews are patient-centered and the use of open-ended questions are used to allow the patient to open up about his or her feelings (Wagner et al., 2016).
Maternal risk factors and FASD are discussed by Cannon et al. (2015), Esper et al. (2014), and Nathan Murawski et al. (2015). The articles listed the most prevalent risk factors for consuming alcohol during pregnancy as well as other risk factors. The other risk factors were not mentioned in every article and included, being single during pregnancy, being less religious, pregnant more than three times, living in a rural area, and beginning drinking at an early age, other children with FASD, use of tobacco and other drugs during pregnancy, fewer prenatal appointments, and complications during previous pregnancies or miscarriages (Esper et al., 2014). These risk factors can all interact to cause a higher risk of consuming alcohol pregnancy, which causes an increased risk for having a child with FASD (Esper et al., 2014).
According to Murawski et al. (2015), studies suggest that women who consume alcohol during pregnancy have nutritional deficiencies. Nutritional deficiencies can lead to abnormal development of the fetus during pregnancy and this lack of nutrients can cause the fetus to be more susceptible to the effects of alcohol. Nutritional supplementation during pregnancy can help reduce the effects of alcohol. However, studies suggest that even small amounts of alcohol can cross the placenta and cause damage to the fetus. Therefore, alcohol should be avoided altogether during pregnancy (O’Brien, 2014).
Fetal alcohol spectrum disorders are a group of major health problems that can be prevented and maternal alcohol consumption can be treated if caught before it causes any harm to the fetus. The timing of interventions to prevent adverse effects of maternal alcohol consumption is crucial to prevent harm to the fetus and mother. Screenings, including SBIRT, TWEAK, and T-ACE, are reliable evidenced-based tools that can be used to screen women for alcohol consumption risk and their level of alcohol consumption (O’Brien, 2014; Lacey, 2016). These screenings should be used more often and at every first prenatal visit to help reduce the occurrence of maternal alcohol consumption and FASD. Those at risk can be identified through these screenings and can be referred to treatment programs (Lacey, 2016). Screening women who are intending to become pregnant should also be performed to assess risk factors that can put them at a higher risk for maternal alcohol consumption.
The articles selected for this research paper thoroughly discussed the risks of alcohol consumption by pregnant women, non-pregnant women, and women who had intentions of becoming pregnant. They compared the results and determined risk factors for maternal drinking as well as tools that can be used to help the women recognize and acknowledge their problem. The authors made recommendations as to how health care providers can increase their use and knowledge of tools, such as SBIRT, TWEAK, and T-ACE in order to provide quality care to women who are at risk for alcoholism or who are currently drinking.
The article by Andrew J. Wagner et al. (2016) was written about the general population instead of just women and non-pregnant women. Although the tools can also be used to treat alcohol consumption in the general population, the focus of this paper was on alcohol consumption during pregnancy. Many health care providers are not implementing SBIRT, TWEAK, and T-ACE, which results in a lack of research regarding the success of these tools. Limited research has been done on the interactions of the risk factors and how they all contribute to an maternal alcohol consumption. Many women do not report their use of alcohol and health care providers do not know how to bring up the use of alcohol, which contributes to the lack of implementing the tools that can be used to help these women.
This research has yielded a number of recommendations. Recommendations include the promotion of the use of SBIRT at every first prenatal visit and the use of TWEAK and T-ACE is implemented if SBIRT shows signs of a high risk for maternal alcohol consumption. Lack of knowledge of these tools and how to implement them is one of the main barriers to increasing the use of these tools. Studies should be conducted that evaluate the interactions of the risk factors in the development of maternal alcohol consumption and FASD. Comparing the results of these studies could lead to interventions to help prevent the development of the risk factors associated with maternal alcohol consumption. More education regarding alcohol and its effects on the fetus should be provided to women who intend to become pregnant because many women continue to drink until they know they are pregnant. Alcohol can affect the fetus in the first weeks of life and can cause irreversible damage during those weeks. Those who intend to become pregnant should stop drinking alcohol to prevent risk of damage to the fetus. Many women use this time to stop risky behaviors and become more aware of their risky behaviors. This heightened awareness can be used to help encourage women to stop drinking and provide assistance to those who need it.
The purpose of this research paper was to identify risk factors associated with FASD and to describe interventions that can be used to help prevent the risk factors. The most prevalent risk factors included poverty, homelessness, substance abuse by the partner, and preconception alcohol use with alcohol use before pregnancy being the biggest risk factor for maternal alcohol consumption (Cannon et al., 2015; Esper et al., 2014; Murawski et al., 2015). The literature cited in this paper determined that several screening methods can be used to identify the risk of consuming alcohol during pregnancy and the level of drinking during pregnancy. Maternal alcohol consumption screenings are not performed in many cases. Educating health care workers in preventative screening techniques has the potential to greatly reduce the number of cases of FASD. By providing screenings at every prenatal visit identification of those at risk can help to target preventative measures at those in need. This will help to decrease the prevalence of maternal alcohol consumption and FASD.
Cannon, M., Guo, J., Denny, C., Green, P., Miracle, H., Sniezek, J., & Floyd, R. (2015). Prevalence and Characteristics of Women at Risk for an Alcohol-Exposed Pregnancy (AEP) in the United States: Estimates from the National Survey of Family Growth. Maternal & Child Health Journal, 19(4), 776-782. doi:10.1007/s10995-014-1563-3
Esper, L., & Furtado, E. (2014). Identifying maternal risk factors associated with Fetal Alcohol Spectrum Disorders: a systematic review. European Child & Adolescent Psychiatry, 23(10), 877-889. doi:10.1007/s00787-014-0603-2
Lacey, J. (2016). Reducing alcohol harm: Early intervention and prevention. Community Practitioner, 89(2), 26-29. Retrieved from http://proxygsu-aut1.galileo.usg.edu/login?url=http://search.proquest.com/docview/1764193691?accountid=8439
Murawski, N. J., Moore, E. M., Thomas, J. D., & Riley, E. P. (2015). Advances in Diagnosis and Treatment of Fetal Alcohol Spectrum Disorders. Alcohol Research: Current Reviews, 37(1), 97-108.
O’Brien, P. (2014). Performance Measurement: A Proposal to Increase Use of SBIRT and Decrease Alcohol Consumption During Pregnancy. Maternal & Child Health Journal, 18(1), 1-9. doi:10.1007/s10995-013-1257-2
Wagner, A. J., Garbers, R., Lang, A., Borgert, A. J., & Fisher, M. (2016). Increasing Follow-up Outcomes of At-Risk Alcohol Patients Using Motivational Interviewing. Journal Of Trauma Nursing, 23(3), 165-168. doi:10.1097/JTN.0000000000000200