The National Association of Nurse Practitioners in Women’s Health (NPWH) supports women’s health nurse practitioners (WHNPs) and other nurse practitioners (NPs) who provide healthcare for reproductive-aged women in the use of evidence-based strategies to prevent alcohol-exposed pregnancies (AEP). Use of these strategies should extend to alcohol screening at least yearly for all adolescent and adult patients. In addition, all sexually active, reproductive-aged women who could become pregnant and who drink alcohol should be counseled about the potentially deleterious effects of alcohol on a developing fetus. They should be advised to use effective contraception to prevent pregnancy or to stop drinking alcohol. Women who are trying to get pregnant should be advised to abstain from drinking alcohol. Pregnant women should be screened for alcohol use at their initial prenatal visit and during each trimester thereafter.1 For those who screen positive for risky alcohol use, NPs should provide a brief behavioral intervention, refer them to specialty services as needed, and plan appropriate follow-up.
Furthermore, NPWH recognizes that early and regular prenatal care for women with alcohol dependence is essential in order to encourage healthy behaviors and provide support and early treatment referrals to reduce risks of harm. Laws that require reporting of alcohol/substance abuse during pregnancy as potential child abuse or ne glect may deter women with alcohol dependence from seeking prenatal care.2,3 Therefore, NPWH opposes policies that require reporting or criminalization of alcohol/substance abuse during pregnancy and supports repeal of existing laws with such mandates. NPWH will provide leadership and collaborate with other organizations and agencies to deliver education and skills training for NPs, develop policies, and conduct and/or support research in a concerted effort to prevent AEP.
Prenatal alcohol exposure is the No. 1 preventable cause of birth defects and intellectual and developmental disabilities in children. Alcohol, a known teratogen, readily crosses the placenta and persists in amniotic fluid after a woman’s serum alcohol level metabolizes to zero. Toxicity is dose related, with the greatest risk to the fetus in the first trimester.4 With regard to preventing fetal alcohol spectrum disorders (FASD) and other adverse pregnancy and birth outcomes associated with prenatal alcohol exposure, there is no known safe amount of alcohol use at any time during pregnancy.
FASD is an umbrella term describing a range of possible effects that include physical, intellectual, behavioral, and learning disabilities and language delays, with lifelong implications for individuals prenatally exposed to alcohol.5 FASD are completely preventable if alcohol is not consumed during pregnancy. But many pregnant women do drink alcohol; the estimated prevalence of FASD in first-grade students in the United States is 2%-5%.6 The lifetime cost of caring for an infant with fetal alcohol syndrome, a single disorder within the FASD continuum, is approximately $2 million.7 In addition to FASD, alcohol use during pregnancy is associated with increased risks for spontaneous abortion, intrauterine growth restriction, stillbirth, preterm birth, and sudden infant death syndrome.8
In 2005, the U.S. Surgeon General advised that pregnant women not drink any alcohol, pregnant women who have already consumed alcohol stop doing so, and women considering becoming pregnant abstain from drinking alcohol.9 Despite this recommendation, the number of women who drink alcohol while pregnant has not decreased significantly.10 Ten percent of pregnant women report drinking some amount of alcohol in the past month and 3.1% report binge drinking.10
The fact that about one-half of all pregnancies are unplanned poses a particular challenge to the prevention of AEP. Approximately 3.3 million reproductive-aged women report drinking alcohol in the past month and having sex without using contraception.11 An additional challenge is that only 1 in 6 U.S. adults reports ever having talked with a healthcare professional about their drinking.11 Therefore, many adults may be unaware of the potential risks of alcohol use to their own health or to the health of a developing fetus.
Implications for women’s healthcare and WHNP practice
Strong evidence suggests that alcohol screening and brief intervention (SBI) is effective in reducing risky alcohol use among women of childbearing age.12,13 Leading U.S. healthcare organizations and agencies, including the U.S. Preventive Services Task Force,14 the CDC,11 and the American College of Obstetricians and Gynecologists,15 recommend that alcohol SBI be implemented at least yearly for all adults in primary care settings. Likewise, all pregnant women should be screened at the first prenatal visit and once during each trimester thereafter.
Alcohol SBI involves using a validated screening tool to identify a woman’s drinking patterns, whether her alcohol consumption is creating a health risk for herself or others, and whether she has symptoms of dependency. If at-risk drinking is identified, the NP engages the woman in a brief motivation-enhancing intervention to reduce drinking. The main goal of alcohol SBI is to motivate patients to be aware of their alcohol consumption patterns, understand the associated risks and options for reducing or eliminating the risk, and make their own decisions. Referral to specialty care for further assessment and treatment is made if a woman is unable to moderate risky alcohol use on her own. The CDC’s Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use: A Step-by-Step Guide for Primary Care Practices provides guidance for incorporating universal alcohol SBI within clinical practice.7 This guide includes information on the use of a variety of screening tools validated for use with adults, including pregnant women.
WHNPs and other NPs who provide healthcare for reproductive-aged women have a responsibility to provide clear, fact-based information regarding risks associated with drinking any amount of alcohol during pregnancy. Furthermore, they have the responsibility to identify women with at-risk drinking habits and provide counseling and referrals for treatment as appropriate.
WHNPs and other NPs who provide healthcare for reproductive-aged women should:
• Adopt a non-judgmental respectful approach when broaching the topic of alcohol use.
• Counsel each reproductive-aged woman in their care that there is no safe amount of alcohol consumption during pregnancy and provide fact-based information regarding risks.
• Provide alcohol screening with a validated screening tool annually and during each trimester of pregnancy.
• Provide an evidence-based brief intervention when at-risk alcohol use is identified.
• Advise all pregnant women who drink alcohol to stop doing so.
• Advise all women planning a pregnancy who drink alcohol to stop doing so.
• Advise all sexually active women who drink alcohol and could become pregnant to use effective contraception to prevent pregnancy or to stop drinking.
• Recognize that not all women are able to stop using alcohol without support.
• Refer women for additional services if they cannot stop drinking on their own. Know which services are available in the community.
• Provide follow-up as needed to monitor women’s drinking, provide encouragement and support, and, if necessary, refer for specialized help.
• Be aware of state reporting laws for alcohol/substance abuse in pregnancy and advocate for retraction of legislation that exposes pregnant women with alcohol dependence to criminal or civil penalties.
NPWH will provide leadership and resources to ensure that:
• Educational programs for NP students with a population focus that includes reproductive-aged women impart evidence-based knowledge and skill building for the development of competencies to conduct effective alcohol SBI to prevent or address alcohol use during pregnancy.
• CE programs are available for NPs to obtain evidence-based knowledge and competencies to conduct effective alcohol SBI to prevent or address alcohol use during pregnancy.
1. Nocon J. Chapter 15: Substance use disorders. In Mattison DR, ed. Clinical Pharmacology During Pregnancy. Amsterdam: Academic Press, an Imprint of Elsevier; 2013.
2. ACOG. Committee on Health Care for Underserved Women. Committee opinion no. 473: Substance abuse reporting and pregnancy: the role of the obstetriciangynecologist. Obstet Gynecol. 2011;117(1):200-201. Reaffirmed 2014.
3. Guttmacher Institute. Substance Abuse During Pregnancy. Washington, DC: Author; 2014.
4. Mattison DR, ed. Clinical Pharmacology During Pregnancy. Amsterdam: Academic Press, an Imprint of Elsevier; 2013.
5. Sokel RJ, Delaney-Black V, Nordstrom B. Fetal alcohol spectrum disorder. JAMA. 2003;290(22):2996-2999.
6. May PA, Baete A, Russo J, et al. Prevalence and characteristics of fetal alcohol spectrum disorders. Pediatrics. 2014;134(5):855-866.
7. CDC. Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use: A Step-by-Step Guide for Primary Care Practices. Atlanta, GA: CDC National Center on Birth Defects and Developmental Disabilities; 2014.
8. Bailey BA, Sokol RJ. Prenatal alcohol exposure and miscarriage, stillbirth, preterm delivery, and sudden infant death syndrome. Alcohol Res Health. 2011;34(1):86-91.
9. U.S. Department of Health and Human Services. U.S. Surgeon General Releases Advisory on Alcohol Use in Pregnancy. Washington, DC: US Department of Health and Human Services; 2005.
10. Tan CH, Denny CH, Cheal NE, et al. Alcohol use and binge drinking among women of childbearing age – United States, 2011-2013. MMWR Morb Mortal Wkly Rep. 2015;64(37):1042-1046.
11. Green PP, McKnight-Eily LR, Tan CH, et al. Vital signs: alcohol-exposed pregnancies—United States, 2011-2013. MMWR Morb Mortal Wkly Rep. 2016; 65(4):91-97.
12. Bertholet N, Daeppen JB, Wietlisbach V, et al. Reduction in alcohol consumption by brief alcohol intervention in primary care: systematic review and metaanalysis. Arch Intern Med. 2005;165(9):986-995.
13. Jonas DE, Garbutt JC, Amick HR, et al. Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2012;157(9):645-654.
14. Moyer VA; Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. preventive services task force recommendation statement. Ann Intern Med. 2013;159(3):210-218.
15. ACOG. Committee on Health Care for Underserved Women. Committee opinion no. 496: At-risk drinking and alcohol dependence: obstetric and gynecologic implications. Obstet Gynecol. 2011;118(2 pt 1):383-388. Reaffirmed 2013.
Approved by the NPWH Board of Directors: August 2016