Drinking for Two: Why We Need to Prevent Alcohol Use During Pregnancy

It was forty years ago that Fetal Alcohol Syndrome (FAS) was first diagnosed by Drs. David Smith and Kenneth Jones at the University of Washington, when a group of babies born to different mothers who consumed alcohol during pregnancy were noticed to have similar physical and behavioral problems. In 2004 the term “Fetal Alcohol Spectrum Disorders” (FASD) came into use, recognizing that children born to women who drank during pregnancy may exhibit a range of physical, mental, and behavioral problems, including learning disabilities. FASD is a descriptive term – not a diagnostic term; FAS is the medical diagnosis in the International Classification of Diseases (ICD).

Because this is a spectrum disorder, problems that are experienced due to prenatal alcohol exposure can range from moderate to severe in an individual, depending on the dose, frequency and timing of when the mother drank, along with other maternal and genetic factors. All types of alcohol are potentially harmful. The alcohol consumed by the mother passes through the placenta to the developing fetus, where it cannot be metabolized because the baby’s liver is not yet fully developed. The baby absorbs all of the alcohol, resulting in the same blood alcohol content as the mother. It is important to note that not all babies prenatally exposed to alcohol will be adversely affected; however, there is no way to predict which fetus will have an FASD – since each person metabolizes alcohol differently. The only safe amount of alcohol to use during pregnancy is none.

Combined 2011 and 2012 data from the National Survey on Drug Use and Health (NSDUH) indicate that 18% of pregnant women drink alcohol during early pregnancy (first trimester). The study did show that the level of alcohol use dropped sharply among pregnant women in their second and third trimesters, suggesting that many pregnant women are getting the message and abstaining from alcohol use during pregnancy.

Studies show that even low levels of alcohol consumption during pregnancy (a range from one drink per week to one drink per day) have been associated with measurable and long-term effects on the growth and behavior of children. “Light drinking” has also been associated with stillbirth, miscarriage and spontaneous abortion. In 2004 the National Institute on Alcohol Abuse and Alcoholism stated, “Thus far, a threshold below which no fetal damage will occur has not been established.” This led to the Surgeon General’s recommendation in 2005 that the safest course is for women to abstain entirely from drinking alcohol during pregnancy. In 2010 the 7th Edition of the Dietary Guidelines for Americans upheld the finding that no safe level of alcohol consumption during pregnancy has been established.

Alcohol is a teratogen, meaning that it can permanently damage the developing fetus during pregnancy. Alcohol is the most common used teratogen by pregnant women, making alcohol use during pregnancy the leading known preventable cause of intellectual disabilities. The prevalence of FASD is nearly the same rate as Autism; and is more prevalent than Down Syndrome, Cerebral Palsy, SIDS, Cystic Fibrosis, and Spina Bifida combined.

According to a report from the Institute of Medicine (IOM), “of all the substances of abuse (including cocaine, heroin, and marijuana), alcohol produces by far the most serious neurobehavioral effects in the fetus.” Binge drinking (defined as four or more drinks in one sitting for women), which exposes a developing fetus to high blood alcohol concentrations, is particularly harmful, and nearly 1 in 8 women in the USA binge drink about three times a month. Statistics from the federal CDC indicate that women aged 18-34 and high school girls are the most likely to binge drink.

No one knows for certain how many individuals are born each year with an FASD or living with an FASD. According to the SAMHSA FASD Center for Excellence, it is estimated that 1 in 100 live births are affected by prenatal alcohol exposure annually, and approximately 1 in 1,000 live births are diagnosed with FAS. It is estimated that nationally, 40, 000 babies are born each year with an FASD. These figures suggest that it is imperative to make women aware of the risks of drinking alcohol during pregnancy,

Many women do not realize they are pregnant until well into the first trimester, and drink alcohol during this time. Research indicates that teenagers tend to recognize their pregnancies later than adults. An estimated 40% of the 60 million US women in their childbearing years do not practice contraception, and approximately half of all pregnancies in this country are unplanned.

Requiring services across the lifespan, FASD is a lifelong disability with health costs for an individual with FAS ranging from $860,000 to $4.2 million. The cost of FASD in the United States exceeds $6 billion annually, and individuals living with FASD are found in every system of care, including: child welfare, mental health, developmental disabilities, vocational services, juvenile and adult justice systems, substance abuse, housing, and physical health. If FASD goes undiagnosed and unaddressed, research shows that these individuals are at high risk for secondary disabilities, such as substance abuse, mental health, dependent living, unemployment, homelessness, and incarceration.

Additionally, this being identified as a spectrum disorder, not every individual with prenatal alcohol exposure will face the same issues as others with FASD. In general, the kinds of issues faced by a person with FASD can include: lower IQ, impaired ability in reading, spelling, and arithmetic, and lower level of adaptive functioning, which can be more significantly impaired than their IQ. Overall difficulties can include: taking in information, storing information, recalling information when necessary; and using information appropriately in a specific situation. Typical problems might include: sensory integration, memory problems, executive functioning, self-esteem and personal issues, and information processing functions.

FASD is 100% preventable if a pregnant woman abstains from drinking alcohol. Reducing the rate of alcohol use during pregnancy must be confronted on several fronts, including raising awareness among the general public and the media, educating service providers who assist pregnant women and women of child-bearing age, and intervening with women who are at risk of having an alcohol-exposed pregnancy. There are many successful programs that work to help women directly—two such programs are Project CHOICES and alcohol Screening and Brief Intervention (SBI).

Project CHOICES is an evidence-based program developed by the federal CDC. It is designed to prevent alcohol-exposed pregnancies by addressing both risky drinking and ineffective or no use of contraception. Project CHOICES has been implemented with women of child-bearing age (as well as pregnant women) in a variety of settings: substance abuse treatment, mental health facilities, jails, primary care, OBGYN clinics, and other community-based settings. The intervention uses either a 2-visit or 4-visit model, plus a contraceptive visit. Project CHOICES relies on Motivational Interviewing techniques to help facilitate positive behavior change. It is relatively brief and can positively impact treatment engagement and retention for women enrolled in addiction treatment. The use of alcohol screening and brief intervention (SBI) to address risky drinking has been endorsed by the U.S. Preventative Services Task Force. For pregnant women, any amount of alcohol would be considered risky behavior. The elements in effective brief interventions are generally consistent with the 5-A’s approach (assess, advise, agree, assist, arrange) to behavioral counseling interventions adopted by the Task Force in 2004. There are several evidence-based screening tools that have been validated for use with women and pregnant women. SBI can be administered easily, effectively, and fairly quickly within a diversity of health care settings. Implementation of the Affordable Care Act includes coverage of certain preventive health services, including alcohol screening women who are pregnant or trying to get pregnant.

The federal government, through the Substance Abuse Services Mental Health Administration (SAMHSA) FASD Center for Excellence, is currently working with states and local communities to spread the implementation of these two evidence-based strategies. These efforts will go a long way in our efforts to reduce the prevalence of Fetal Alcohol Spectrum Disorders in our society.

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