Routine and universal alcohol screening is an effective strategy to prevent prenatal alcohol exposure (PAE).
The American College of Nurse-Midwives (ACNM) encourages all certified nurse-midwives (CNMs), certified midwives (CMs), and other reproductive health professionals to conduct universal alcohol screening as part of routine preconception and prenatal care (American College of Nurse-Midwives, 2017). Asking about behaviors (e.g., smoking, nutrition, physical activity, contraception use) and providing relevant advice and education is what CNMs and CMs routinely do. Yet, many of us do not ask our clients about their alcohol use, except perhaps in the context of a new prenatal encounter. While there are important reasons to ask about alcohol, given its teratogenicity, there are barriers that can influence both clinical practice and the receptivity of clients to “hearing the message”.
Women’s alcohol use has been increasing, and heavy use is normalized.
Social norms today espouse an ‘anything goes’ attitude about alcohol use. We are exposed to conflicting and misinformation on social media, mainstream media ‘modeling’ of alcohol consumption, and visuals or memes that have normalized alcohol use for women as celebratory, social, and as a coping strategy for depression and stress (Peltier et al., 2019). In recent years, the prevalence of women drinking during pregnancy (one in nine) and a heavy use pattern (eight or more standard drinks per week) have become more common (Denny, et al., 2019; Slade et al., 2016). When excessive alcohol use is combined with the fact that only 60% of American women of reproductive age use a form of contraception (Kavanaugh & Jerman, 2018), there is great concern about the potential for unintended pregnancy and PAE.
Clients and professionals may not understand FASD.
Fetal alcohol spectrum disorders (FASDs) are lifelong disabilities that can manifest slowly over time. Fetal alcohol syndrome (FAS), a relatively rare condition along the continuum of FASDs associated with distinctive facial features, is associated with consuming alcohol early in pregnancy. Other FASDs, on the other hand, may be invisible at birth and present over time as the child experiences difficulties in regulation, attention, learning, behavior, and social skills. One in 20 school-age children in the U.S. may have an FASD, according to current prevalence estimates (May et al., 2018).
You may be concerned your clients will be offended or think you are judging them.
Alcohol and substance use disorders are highly stigmatized conditions (Keyes, et al. 2010). Stigma on the part of both the midwife and client can prevent us from having thoughtful conversations about how someone is using alcohol. Our own biases about who might be ‘drinking’ and the clients’ fears about being stereotyped, judged, or shamed if they disclose their alcohol (or other substance) use are important factors we need to consider (Edwards et al., 2020).
You want to ask, but don’t know how best to carry out standardized alcohol screening.
The single question alcohol screener, “How many times in the past year have you had four or more drinks in a day?” is a validated way to identify unhealthy alcohol use (Smith et al, 2009). The single question is valuable if you experience system barriers such as tight appointment times, lack of a standardized screening tool, inability to document screening in the health record, lack of ‘buy-in’ from management, or lack of provider training in alcohol screening and brief intervention.
As trusted health professionals, midwives can learn to use helpful tools and tips to develop an honest, matter-of-fact attitude about routine alcohol screening. Bookmarking resources and information sites and incorporating insightful visual conversation aids and other tools in our clinical practice can help normalize the conversation about alcohol. Ultimately, alcohol is no different from any other health risks we screen for, such as tobacco use, hypertension, diabetes, or cancer. Routine conversations in clinical practice can reduce stigma and biases.
Learn more about how to use alcohol screening and brief intervention to help reduce stigma and bias at the presentation, Universal Alcohol Screening and Brief Intervention as Routine Clinical Practice: A Strategy for Reducing Alcohol Use During Pregnancy and Overcoming Barriers to Treatment,at the upcoming ACNM 66th Annual Meeting, held virtually May 23–25, 2021.
Authors
Marilyn Pierce-Bulger, APRN, CNM; Alexandra Edwards, MA; Hannah Rebadulla, BA; Beth Kelsey, EdD, WHNP-BC; Lily Bastian, CNM; Catherine Ruhl, DNP, CNM; and Diane K. King, PhD
References
American College of Nurse-Midwives. (2017). Position statement: Screening and brief intervention to prevent alcohol-exposed pregnancy. American College of Nurse-Midwives. Retrieved from www.midwife.org/acnm/files/ACNMLibraryData/UPLOADFILENAME/000000000309/ScreeningBriefInterventionPreventAlcoholExposedPregnancyMay2017.pdf
Denny, C.H., Acero, C.S., Naimi, T.S., Kim, S.Y. (2019). Consumption of alcohol beverages and binge drinking among pregnant women aged 18-44 years – United States, 2015-2017. MMWR Morbidity and Mortality Weekly Report, 68(16): 365-368.
Edwards, A., Kelsey, B., Pierce‐Bulger, M., Rawlins, S., Ruhl, C., Ryan, S. and King, D.K. (2020), Applying ethical principles when discussing alcohol use during pregnancy. Journal of Midwifery & Women’s Health, 65, 795-801. https://doi.org/10.1111/jmwh.13159
Kavanaugh, M.L., & Jerman, J. (2018). Contraceptive method use in the United States: trends and characteristics between 2008, 2012 and 2014. Contraception, 97(1), 14–21. https://doi.org/10.1016/j.contraception.2017.10.003.
Keyes, K.M., Hatzenbuehler, M.L., McLaughlin, K.A., Link, B., Olfson, M., Grant, B.F., & Hasin, D. (2010). Stigma and treatment for alcohol disorders in the united states. American Journal of Epidemiology, 172(12), 1364-1372. https://doi.org/10.1093/aje/kwq304
May, P.A., Chambers, C.D., Kalberg, W.O., Zellner, J., Feldman, H., Buckley, D., Kopald, D., Hasken, J.M., Xu, R., Honerkamp-Smith, G., Taras, H., Manning, M.A., Robinson, L.K., Adam, M.P., Abdul-Rahman, O., Vaux, K., Jewett, T., Elliott, A.J., Kable, J.A., Akshoomoff, N., Hoyme, H.E. (2018). Prevalence of fetal alcohol spectrum disorders in 4 US communities. JAMA, 319(5), 474–482. https://doi.org/10.1001/jama.2017.21896.
Peltier, M.R., Verplaetse, T.L., Mineur, Y.S., Petrakis, I.L., Cosgrove, K.P., Picciotto, M.R., & McKee, S.A. (2019). Sex differences in stress-related alcohol use. Neurobiology of Stress, 10, 100149. https://doi.org/10.1016/j.ynstr.2019.100149
Slade T, Chapman C, Swift W, Keyes K, Tonks Z, & Teesson M. (2016). Birth cohort trends in the global epidemiology of alcohol use and alcohol-related harms in men and women: systematic review and metaregression. BMJ Open 6:e011827. doi:10.1136/bmjopen-2016-011827.
Smith, P.C., Schmidt, S.M., Allensworth-Davies, D., & Saitz, R. (2009). Primary care validation of a single-question alcohol screening test. Journal of General Internal Medicine, 24(7), 783–788. https://doi.org/10.1007/s11606-009-0928-6
Disclaimer: This work is supported by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC) Cooperative Agreement Number NU84DD000006. These contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC, the U.S. Department of Health and Human Services, or University of Alaska Anchorage Institute of Social and Economic Research.
