Project CHOICES Research Group. Alcohol-exposed pregnancy: characteristics associated with risk

Community Perceptions of Alcohol Exposed Pregnancy Prevention Program for American Indian and Alaska Native Teens

A community needs assessment during a tribally-led Changing High-Risk Alcohol Use and Increasing Contraception Effectiveness Study (CHOICES) intervention highlighted the need to reduce the risk for alcohol exposed pregnancy (AEP) among American Indian and Alaska Native (AIAN) adolescent girls. The CHOICES for American Indian Teens (CHAT) Program aims to reduce the risk of AEP among AIAN teens in one Northern Plains tribal community. The CHAT team adopted an iterative process to modify the tribally-led CHOICES curriculum for AIAN teens. This paper describes the iterative process as well as the community perception towards AEP prevention among AIAN teens. The CHAT team conducted several levels of formative and qualitative research, including one-on-one interviews (n = 15) with community members, AIAN elders and school counsellors; and three focus groups with AIAN adolescent girls (n = 15). A qualitative data analysis identified several recommendations that centered on making the information regarding alcohol and birth control appealing to teens; ensuring the confidentiality of the participants; making the program culturally relevant; and including boys in the program. This study outlines various components prioritized by community members in creating a culturally-relevant and age-appropriate AEP prevention program and provides community perceptions of AEP prevention for the teens in this community.

"But Problems Dwell so the Urge Is Constant…" Qualitative Data Analysis of the OST CHOICES Program

BACKGROUND

Fetal alcohol spectrum disorders are a major public health concern including among American Indian (AI)/Alaska Native (AN) communities. Various studies have demonstrated higher alcohol consumption among AI/AN women during pregnancy compared with other groups. This study intends to understand the milieu within which such consumption patterns flourish. The study utilizes qualitative and quantitative data from the Oglala Sioux Tribe (OST) CHOICES Program, a tribally run public health program that aims to reduce alcohol-exposed pregnancy preconceptually in AI women.

METHODS

Alcohol consumption pattern (n = 264) is analyzed using descriptive statistics. Consumption patterns included average drinks consumed daily, their choice of drinks (beer, whiskey, wine, etc.), how much money participants were spending on alcohol and amount of calories consumed from alcohol. Qualitative data analysis included open coding of data from decisional balance exercise of the CHOICES program that looked at good things and not so good things about participants' drinking.

RESULTS

Women reported drinking an average of 12 drinks daily, ranging between 1 and 86. Women drinking at home spent a median of $4,320 and $12,960 if drinking at a bar. A median of 1,200 calories per day from alcohol was reported. More women reported drinking beer compared with other types of alcohol within a domestic setting. Qualitative data analysis identified positive and negative aspects of drinking among the participants of OST CHOICES Program. Positive aspects included escaping from problems, socializing, and relaxation. Negative aspects included impact on families and domestic violence.

CONCLUSIONS

While understanding their milieu, our study also unraveled different struggles (such as violence, peer pressure, financial burden, and depression) encountered by Native women in their daily lives. According to the participants, positive aspects of drinking outweigh the negative aspects and they viewed their drinking as a solution and not a problem.

Changing multiple health risk behaviors in CHOICES

Multiple health behavior change (MHBC) intervention trials to date have only considered behaviors that were directly targeted. Research has yet to consider how untargeted behaviors can affect change in behaviors directly targeted by an intervention or how changes in targeted behaviors might lead to changes in other, untargeted behaviors. This study addresses these gaps with a secondary analysis of change in risk drinking (targeted behavior) and smoking (behavior that was not addressed) in the efficacy trial of CHOICES, an intervention for the prevention of alcohol-exposed pregnancies. Measures included the Timeline Followback for daily alcohol consumption and questions about smoking behavior. Participants were women of childbearing age who were at risk of alcohol-exposed pregnancy at baseline. Baseline smokers were less likely to change their drinking behavior than baseline non-smokers at nine months (n = 579) with Odds Ratio (OR) of 0.681 (95% CI = 0.471–0.985); 41.1% of smokers vs 50.6% of non-smokers reduced drinking to below risk levels (<5 drinks/day and < 8 drinks per week). Meanwhile, smokers who had changed their drinking behavior were more likely than smokers who had not changed their drinking behavior to have also quit smoking at nine months (OR = 2.769; 95% CI = 1.533–5.000); 19.5% vs. 8.1%, respectively. Together, these findings suggest a natural tendency towards change of multiple related behaviors and indicate that while the presence of unaddressed risk behaviors may make a targeted behavior change more difficult, change in one behavior may facilitate change in related behaviors, even when they are not addressed.

A Pilot RCT of an Internet Intervention to Reduce the Risk of Alcohol-Exposed Pregnancy

BACKGROUND

Preventing alcohol-exposed pregnancies (AEPs) could reduce the incidence of fetal alcohol spectrum disorders. Previous face-to-face interventions significantly reduced risk for AEP, but a scalable intervention is needed to reach more women at risk.

METHODS

This study compared a 6 Core automated, interactive, and tailored Internet intervention, the Contraception and Alcohol Risk Reduction Internet Intervention (CARRII), to a static patient education (PE) website for its effect on AEP risk. Participants were recruited online to a pilot randomized clinical trial (RCT) with baseline, 9 weeks posttreatment, and 6-month (6-M) follow-up assessments. Seventy-one women completed online questionnaires and telephone interviews and were randomized to CARRII (n = 36) or PE (n = 35). Primary outcomes were rates of risky drinking, unprotected sex episodes, and AEP risk, collected from online prospective diaries.

RESULTS

CARRII participants showed significant reductions in rate of unprotected sex from pretreatment (88.9%) to posttreatment (70.6%) (p < 0.04) and to 6-M follow-up (51.5%) (p = 0.001); rate of risky drinking from pretreatment (75.0%) to posttreatment (50.0%) (p < 0.02), but insignificant change from pretreatment to 6-M follow-up (57.6%) (p < 0.09); and rate of AEP risk from pretreatment (66.7%) to posttreatment (32.4%) (p = 0.001) and to 6-M follow-up (30.3%) (p = 0.005). PE participants demonstrated no significant changes on all 3 variables across all time points. Intent-to-treat group-by-time tests were not significant, but power was limited by missing diaries. Over 72% of CARRII participants completed all 6 Cores. Exploratory analyses suggest that higher program utilization is related to change.

CONCLUSIONS

These data show that CARRII was acceptable, feasible, promising to reduce AEP risk, and merits further testing in a fully powered RCT.

Fetal Alcohol Spectrum Disorders: Characteristics, Complications, and Treatment

Fetal Alcohol Spectrum Disorders (FASD) includes a continuum of disorders that occur in children as a result of their mothers' consumption of alcohol during pregnancy. The most severe of these disorders is Fetal Alcohol Syndrome (FAS). FASD presents differently in every child, but all children with FASD have intellectual and/or behavioral impairments. There is no cure for FASD, but research shows that early intervention and life-long support help those born with FASD to manage the difficulties that come with it. This paper examines the characteristics, complications, and treatment for FASD.

Preventing Alcohol-Exposed Pregnancies: A Randomized Controlled Trial of a Self-Administered Version of Project CHOICES with College Students and Nonstudents

BACKGROUND

Alcohol-exposed pregnancies (AEPs) are a preventable cause of birth defects and developmental disabilities for which many women are at risk. The initial 5-session Project CHOICES intervention was found to prevent AEPs. In the ensuing decade, there have been several additional CHOICES-like studies. This study, Project Healthy CHOICES, had 2 objectives: (i) to compare outcomes for students versus nonstudents; and (ii) to test a self-administered mail-based version of the Project CHOICES intervention.

METHODS

A randomized controlled trial (RCT) compared 2 interventions for women of childbearing age (18 to 44) who were at risk of an AEP: (i) motivational feedback based on Project CHOICES and (ii) information only. Advertisements recruited 354 women (145 college students; 209 nonstudents) at risk of an AEP. Intervention and study materials were available in English and Spanish. Of the 354 women, 44% were minorities (25% identified as Hispanics).

RESULTS

At the 6-month follow-up, the interventions did not differ and there was no Intervention by Student Study interaction. However, over the entire 6-month follow-up, significantly more students (68%) than nonstudents (46%) were not at risk of an AEP (2.1 odds ratio; confidence interval = 1.47 to 2.95). For all groups, risk reduction occurred primarily through effective contraception.

CONCLUSIONS

There was no significant difference between the 2 interventions. However, over the entire 6-month follow-up interval, college students were significantly more likely than nonstudents to not be at risk of an AEP and to use effective contraception. While the student groups had significantly higher reduced risk of AEP outcomes, there was also substantial risk reduction for women in the information only condition. These results suggest that the most effective AEP prevention efforts would be to inform women at risk that they could become pregnant. Because about half of all pregnancies are unplanned, identifying women at risk and preventing the risk of AEPs should be a public health priority.

Impact of the CHOICES Intervention in Preventing Alcohol-Exposed Pregnancies in American Indian Women

BACKGROUND

Fetal alcohol spectrum disorders (FASD) comprise a continuum of lifelong outcomes in those born prenatally exposed to alcohol. Although studies have shown no differences in rates by race, FASD is of particular concern for American Indian communities. One tribally run prevention program is the Oglala Sioux Tribe (OST) CHOICES Program, which is modeled after the evidence-based CHOICES program that was focused on preconceptional prevention of alcohol-exposed pregnancy (AEP) by reducing risky drinking in women at risk for pregnancy and/or preventing unintended pregnancy.

METHODS

The OST CHOICES Program was made culturally appropriate for American Indian women and implemented with 3 communities, 2 on the reservation and 1 off. Data on drinking, sexual activity, and contraception use were collected at baseline and 3 and 6 months postintervention. Data were analyzed using descriptive statistics, 1-way analysis of variance, and a random intercept generalized estimating equation model.

RESULTS

A total of 193 nonpregnant American Indian women enrolled in the OST CHOICES Program, and all were at risk for AEP because of binge drinking and being at risk for an unintended pregnancy. Fifty-one percent of participants completed both 3- and 6-month follow-ups. Models showed a significant decrease in AEP risk from baseline at both 3- and 6-month follow-ups, indicating the significant impact of the OST CHOICES intervention. Women in the OST CHOICES Program were more likely to reduce their risk for AEP by utilizing contraception, rather than decreasing binge drinking.

CONCLUSIONS

Even with minor changes to make the CHOICES intervention culturally and linguistically appropriate and the potential threats to program validity those changes entail, we found a significant impact in reducing AEP risk. This highlights the capacity for the CHOICES intervention to be implemented in a wide variety of settings and populations.

Prenatal Alcohol Consumption Between Conception and Recognition of Pregnancy

BACKGROUND

Current estimates of the rates of alcohol-exposed pregnancies may underestimate prenatal alcohol exposure if alcohol consumption in early trimester 1, prior to awareness of pregnancy, is not considered. Extant literature describes predictors of alcohol consumption during pregnancy; however, alcohol consumption prior to awareness of pregnancy is a distinct behavior from consumption after becoming aware of pregnancy and thus may be associated with different predictors. The purpose of this study was therefore to examine prevalence and predictors of alcohol consumption by women prior to awareness of their pregnancy, and trajectories of change to alcohol use following pregnancy recognition.

METHODS

Pregnant women (n = 1,403) were prospectively recruited from general antenatal clinics of 4 public hospitals in Australian metropolitan areas between 2008 and 2013. Women completed detailed interviews about alcohol use before and after recognition of pregnancy.

RESULTS

Most women (n = 850, 60.6%) drank alcohol between conception and pregnancy recognition. Binge and heavy drinking were more prevalent than low-level drinking. The proportion of women who drank alcohol reduced to 18.3% (n = 257) after recognition of pregnancy. Of women who drank alcohol, 70.5% ceased drinking, 18.3% reduced consumption, and 11.1% made no reduction following awareness of pregnancy. Socioeconomic status (SES) was the strongest predictor of alcohol use, with drinkers more likely to be of high rather than low SES compared with abstainers (OR = 3.30, p < 0.001). Factors associated with different trajectories (either cessation, reduction, or continuation of drinking) included level of alcohol use prior to pregnancy recognition, age, pregnancy planning, and illicit substance use.

CONCLUSIONS

In this sample of relatively high SES women, most women ceased or reduced drinking once aware of their pregnancy. However, the rate of alcohol-exposed pregnancies was higher than previous estimates when the period prior to pregnancy recognition was taken into account.

Processes of change in preventing alcohol exposed pregnancy: A mediation analysis

OBJECTIVE

To examine mechanisms of the treatment effect for CHOICES, a motivational intervention to reduce risk of alcohol exposed pregnancy (AEP). Grounded in constructs from the transtheoretical model (TTM) and motivational interviewing (MI), the intervention targeted: risk drinking (>4 drinks/day or >7 drinks/week); ineffective contraception; and AEP risk (both behaviors). The experiential and behavioral processes of change (POC), posited to describe the mechanisms through which individual behavior change occurs, were examined. It was hypothesized that each of the targeted treatment outcomes at 9-month follow-up would be mediated by the experiential POC at 3 months, and that these would then be mediated by the behavioral POC at 9 months.

METHOD

Eight hundred thirty women at-risk for AEP were randomized to CHOICES (information plus counseling; IPC) condition (n = 416) or information only (IO) condition (n = 414). Primary outcomes and proposed mediators (POC) were assessed at 3 and 9 months. Path analyses using weighted least squares estimation with mean- and variance-adjusted chi-square statistic were conducted separately for each outcome.

RESULTS

Model fit indices indicated good fit, and the indirect effect of treatment on outcome via POC was significant for hypothesized models predicting risky drinking and ineffective contraception. The indirect effect of treatment on AEP risk through POC for ineffective contraception was significant, but the indirect effect of POC for risky drinking was not.

CONCLUSIONS

These findings support the temporal relationship between experiential and behavioral POC consistent with the TTM. Opportunistic, motivation-based interventions may benefit from directly targeting experiential POC early in treatment and behavioral POC later in treatment. (PsycINFO Database Record

Indirect and direct perceived behavioral control and the role of intention in the context of birth control behavior

Unintended pregnancies can have negative consequences for both mother and child. The focus of this study was to utilize perceived behavioral control measures (PBC; part of the theory of planned behavior) to identify relevant behavioral determinants of birth control use. This study also tested associations between direct and indirect PBC measures and intention of birth control use and between intention and birth control use. The methods included a randomly selected sample of patients at a health care system in the Upper Midwest who were sent a self-administered survey, with 190 non-pregnant women returning completed surveys. Participants indicated a high level of control over using birth control, and a significant positive correlation was observed between direct and indirect PBC measures. Participants also reported high intentions to use birth control, and a significant positive correlation was observed between intention and PBC. Additionally, both PBC measures and intention were independently and significantly associated with behavior, and PBC remained significantly associated with behavior when intention was added into the model. In conclusion, compared to the previous literature, this study is unique in that it examines indirect PBC measures and also the important role that PBC plays with actual birth control behavior.

Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE): Proposed DSM-5 Diagnosis

Over the past 40 years, a significant body of animal and human research has documented the teratogenic effects of prenatal alcohol exposure (PAE). Neurobehavioral Disorder associated with PAE is proposed as a new clarifying term, intended to encompass the neurodevelopmental and mental health symptoms associated with PAE. Defining this disorder is a necessary step to adequately characterize these symptoms and allow clinical assessment not possible using existing physically-based diagnostic schemes. Without appropriate diagnostic guidelines, affected individuals are frequently misdiagnosed and treated inappropriately (often to their considerable detriment) by mental health, educational, and criminal justice systems. Three core areas of deficits identified from the available research, including neurocognitive, self-regulation, and adaptive functioning impairments, are discussed and information regarding associated features and disorders, prevalence, course, familial patterns, differential diagnosis, and treatment of the proposed disorder are also provided.

Which women are missed by primary health-care based interventions for alcohol and drug use?

BACKGROUND

Women of reproductive age who binge drink or have alcohol-related problem symptoms (APS) and who do not use contraception are considered at risk of an alcohol-exposed pregnancy (AEP). In the U.S., efforts to prevent AEPs focus largely on delivering interventions in primary health care settings. While research suggests that these interventions are efficacious for women reached, it is unclear to what extent these interventions are likely to reach women at risk of AEPs.

METHODS

Data are from the Turnaway Study, a study of 956 women seeking pregnancy termination at 30 U.S. facilities between 2008 and 2010, some of whom received and some of whom were denied terminations because they were past the gestational limit. We examined associations between binge drinking, APS, and drug use prior to pregnancy recognition and having a usual source of health care (USOC).

RESULTS

Overall, 59% reported having a USOC. A smaller proportion with than without an APS reported a USOC (44 vs. 60%, p<.05) and a smaller proportion using than not using drugs reported a USOC (51 vs. 61%, p<.05). This pattern was not observed for binge drinking. In multivariate analyses, an APS continued to be associated with lack of a USOC, while drug use was no longer associated with lack of a USOC.

CONCLUSIONS

As more than 40% did not have a USOC, with higher proportions among women with an APS, primary health-care based approaches to AEP prevention seem unlikely to reach the majority of women who have an APS and are at risk of an unintended pregnancy.

The Oglala Sioux Tribe CHOICES Program: Modifying an Existing Alcohol-Exposed Pregnancy Intervention for Use in an American Indian Community

Alcohol-exposed pregnancies are a health issue for many American Indian communities. The goal of this manuscript is to outline how an existing alcohol-exposed pregnancy prevention program with non-pregnant women (Project CHOICES) was modified to fit the needs and norms of an American Indian community. The Oglala Sioux Tribe CHOICES Program was developed and implemented using community feedback through initial meetings, reviewing materials, gathering input into recruitment and intervention logistics, and conducting interviews to evaluate the program. The intervention was implemented and has been enrolling non-pregnant American Indian women for the past several years. While data collection is ongoing, it has shown preliminary success in changing behaviors and in impacting how the community views the prevention of alcohol-exposed pregnancies. Overall, this study highlights the potential to expand this prevention program to other sites and with other populations, such as adolescents. By the end of this article, readers will comprehend the steps necessary to replicate such a program at other tribal and rural sites.

Importance of social support in preventing alcohol-exposed pregnancies with American Indian communities

Recent research concludes that prevention of alcohol-exposed pregnancies (AEP) must occur with preconceptional women, either by reducing alcohol consumption in women at-risk or planning pregnancy or preventing pregnancy in women drinking at risky levels. One AEP prevention program currently underway with non-pregnant American Indian women is the Oglala Sioux Tribe (OST) Changing High-risk alcohOl use and Increasing Contraception Effectiveness Study (CHOICES) Program. The OST CHOICES Program shows promise in lowering the AEP risk in American Indian women, and it is a natural next step to evaluate the potential impact that social support can have on further encouraging behavioral changes. Focus groups with community members and key informant interviews with health and social service professionals were completed. To uncover and interpret interrelated themes, a conventional content analysis methodology was used. Eight focus groups were held with 58 American Indian participants, including adult women of child-bearing age, elder women, and adult men. Key informant interviews were completed with 25 health and social service professionals. Based on input from the focus groups and key informant interviews, several subthemes regarding social support in the prevention of AEP stood out, including the role of family (especially elders), the impact community can have, and the important function of culture. In this study, we highlighted the important influence that social support can have on AEP prevention, especially among the American Indian population, where social support has cultural and historical significance.

Preventing alcohol-exposed pregnancy among American-Indian youth

Research has determined that the prevention of alcohol-exposed pregnancies (AEP) must occur pre-conceptually with women, either by reducing alcohol intake in women planning pregnancy or at-risk for becoming pregnant, or by preventing pregnancy in women drinking at risky levels. One such AEP prevention programme with non-pregnant American Indian women is the Oglala Sioux Tribe (OST) CHOICES (Changing High-risk alcohOl use and Increasing Contraception Effectiveness Study) Programme, which shows promise in reducing AEP risk in American Indian women aged 18 or older. A community needs assessment was conducted with key informant interviews and focus groups with an emphasis on how to expand OST CHOICES. To identify interconnected themes, a content analysis methodology was used on the qualitative feedback from the focus groups and interviews. Altogether, key informant interviews were completed with 25 health and social service professionals. Eight focus groups were held with 58 American Indian participants, including adult women of child-bearing age, elder women, and adult men. Several sub-themes regarding the prevention of AEP with youth were identified, expanding the OST CHOICES curriculum into the schools, and the role of family and culture within AEP prevention.

Development and Implementation of CHOICES Group to Reduce Drinking, Improve Contraception, and Prevent Alcohol-Exposed Pregnancies in American Indian Women

Public health officials assert that prevention of alcohol-exposed pregnancies (AEP) should begin before conception, by reducing alcohol consumption in women at-risk for or planning pregnancy, and/or preventing pregnancy in women who are drinking at risky levels. One such effort is the Oglala Sioux Tribe (OST) CHOICES Program. While the OST CHOICES Program has been successfully implemented, a community-based needs assessment determined that the OST CHOICES intervention should expand and be delivered in a group setting using group motivational interviewing (MI) techniques. After extensive group MI and CHOICES group trainings, recruitment for CHOICES Group began and within a ten month period, a total of twelve groups with non-pregnant American Indian women were held for this pilot intervention. Evaluations completed by participants indicated that CHOICES Group sessions positively engaged members, had low levels of anger or tension, and had average levels of avoidance of personal responsibility. An evaluation of the CHOICES Group leaders indicated strengths in certain MI skills, although improvement is needed in some core MI and group leadership skills. This is an important expansion of a successful AEP prevention program (CHOICES), as well as a novel application of MI, and recommendations and future plans for this intervention are outlined.

Establishing survey validity and reliability for American Indians through "think aloud" and test-retest methods

The purpose of this study was to use a mixed-methods approach to determine the validity and reliability of measurements used within an alcohol-exposed pregnancy prevention program for American Indian women. To develop validity, content experts provided input into the survey measures, and a "think aloud" methodology was conducted with 23 American Indian women. After revising the measurements based on this input, a test-retest was conducted with 79 American Indian women who were randomized to complete either the original measurements or the new, modified measurements. The test-retest revealed that some of the questions performed better for the modified version, whereas others appeared to be more reliable for the original version. The mixed-methods approach was a useful methodology for gathering feedback on survey measurements from American Indian participants and in indicating specific survey questions that needed to be modified for this population.

Risk drinking and contraception effectiveness among college women

Risk drinking, especially binge drinking, and unprotected sex may co-occur in college women and increase the risks of STI exposure and pregnancy, but the relationships among these behaviors are incompletely understood. A survey was administered to 2012 women of ages 18-24 enrolled in a public urban university. One-quarter of the college women (23%) drank eight or more drinks per week on average, and 63% binged in the past 90 days, with 64% meeting criteria for risk drinking. Nearly all sexually active women used some form of contraception (94%), but 18% used their method ineffectively and were potentially at risk for pregnancy. Forty-four percent were potentially at risk for STIs due to ineffective or absent condom usage. Ineffective contraception odds were increased by the use of barrier methods of contraception, reliance on a partner's decision to use contraception, and risk drinking, but were decreased by the use of barrier with hormonal contraception, being White, and later age to initiate contraception. In contrast, ineffective condom use was increased by reliance on a partner's decision to use condoms, the use of condoms for STI prevention only, and by risk drinking. Thirteen percent of university women were risk drinkers and using ineffective contraception, and 31% were risk drinkers and failing to use condoms consistently. Risk drinking is related to ineffective contraception and condom use. Colleges should promote effective contraception and condom use for STI prevention and consider coordinating their programs to reduce drinking with programs for reproductive health. Emphasizing the use of condoms for both pregnancy prevention and STI prevention may maximize women's interest in using them.

Alcohol consumption in pregnancy: results from the general practice setting

BACKGROUND

There is no established safe level of alcohol consumption in pregnancy. Studies from Ireland have consistently shown lower abstention and higher binge drinking rates in pregnancy than other countries, indicating a high potential for foetal alcohol-related disorders. There has been little research on alcohol in pregnancy in primary care.

AIMS

To determine the prevalence of alcohol consumption amongst pregnant women attending their GP for antenatal care, and to compare this to use in the year prior to conception.

METHODS

Prospective cross-sectional study was carried out in fifteen teaching practices in the greater Dublin area. Women were recruited at their antenatal visits. Data were gathered by self-completed questionnaire in the practice, or researcher-administered telephone questionnaire. The questionnaire was based on the AUDIT, a WHO-validated data collection instrument designed for use in primary care.

RESULTS

Two hundred and forty valid questionnaires were returned (80 % recruitment rate). Alcohol intake and binge drinking levels were much lower during pregnancy compared to the year prior to pregnancy (p < 0.001). There was a marked reduction in the prevalence of alcohol use in pregnancy compared to previous research. Over 97 % drink no more than once a week, including almost two-thirds of women who abstain totally from alcohol in pregnancy. Non-pregnant Irish women drink alcohol more frequently, and with higher rates of binge drinking, than women of other nationalities.

CONCLUSIONS

Primary care is a suitable setting to research alcohol use in pregnancy. Alcohol use in pregnancy in Ireland has decreased markedly compared to previous research from this jurisdiction.

Feasibility and promise of a remote-delivered preconception motivational interviewing intervention to reduce risk for alcohol-exposed pregnancy

BACKGROUND

Alcohol-exposed pregnancy (AEP) is a leading cause of birth defects. Effective face-to-face preconception interventions based on motivational interviewing (MI) exist and should be translated into remote formats for maximum public health impact. This study investigated the feasibility and promise of a one-session, remote-delivered, preconception, MI-based AEP intervention (EARLY Remote) for non-treatment-seeking community women.

SUBJECTS AND METHODS

This was a single-arm, prospective pilot intervention study. All participants received the intervention via telephone and mail. Feasibility of remote-delivery methods, treatment engagement, treatment credibility, MI treatment integrity, and therapeutic alliance were examined. Outcomes were 3- and 6-month drinks per drinking day (DDD), rate of unreliable contraception, and proportion of women at risk for AEP due to continued risk drinking and no or unreliable contraception use.

RESULTS

Feasibility of remote delivery was established; participants were engaged by the intervention and rated it as credible. Integrity to MI and therapeutic alliance were good. Both DDD and rate of unreliable contraception decreased significantly over time. Proportions of women who drank at risk levels, used unreliable or no contraception, and/or were at risk for AEP in the past 90 days decreased significantly from baseline to 6 months.

CONCLUSIONS

Remote delivery was feasible, and the translated remote intervention may reduce AEP risk. Refinement of EARLY Remote may facilitate its placement within a spectrum of effective MI-based preconception AEP interventions as part of a stepped-care approach. EARLY Remote may have an important role within a stepped-care model for dissemination to geographically disperse women at risk for AEP. This could result in substantial public health impact through reduction of AEP on a larger scale.

Preconceptional motivational interviewing interventions to reduce alcohol-exposed pregnancy risk

Alcohol exposed pregnancy (AEP) is a leading cause of preventable birth defects. While randomized controlled trials (RCTs) have shown that multi-session motivational interviewing-based interventions reduce AEP risk, a one-session intervention could facilitate broader implementation. The purposes of this study were to: (1) test a one-session motivational AEP prevention intervention for community women and (2) compare outcomes to previous RCTs. Participants at risk for AEP (N=217) were randomized to motivational interviewing+assessment feedback (EARLY), informational video, or informational brochure conditions. Outcomes were drinks per drinking day (DDD), ineffective contraception rate, and AEP risk at 3 and 6 months. All interventions were associated with decreased DDD, ineffective contraception rate, and AEP risk. Participants who received EARLY had larger absolute risk reductions in ineffective contraception and AEP risk, but not DDD. Effect sizes were compared to previous RCTs. The one-session EARLY intervention had less powerful effects than multi-session AEP prevention interventions among community women, but may provide a new option in a continuum of preventive care.

CHOICES: an integrated behavioral intervention to prevent alcohol-exposed pregnancies among high-risk women in community settings

CHOICES is an integrated behavioral intervention for prevention of prenatal alcohol exposure in women at high risk for alcohol-exposed pregnancies. The intervention uses motivational interviewing and cognitive-behavioral strategies, and targets adoption of effective contraception and reduction of alcohol use. The CHOICES intervention includes four manual-guided counseling sessions delivered by behavioral health counselors and one contraceptive session with a family planning clinician. CHOICES's efficacy has been established through a series of randomized controlled trials in settings including primary care, university hospital-based obstetrical/gynecology practices, urban jails, substance abuse treatment settings, and a media-recruited sample in three large cities. This article describes the CHOICES line of research including the epidemiology, feasibility, and efficacy studies. It also details the CHOICES intervention and the components of each session. In addition, the authors describe current studies testing modifications of the CHOICES intervention, the dissemination efforts to date, and implications for social work practice.

Prevention of alcohol-exposed pregnancies among nonpregnant American Indian women

PURPOSE

The goal of this project was to evaluate an intervention on reducing alcohol-exposed pregnancies with nonpregnant American Indian women, with a focus on risky drinking and ineffective contraception use.

DESIGN

This study had a descriptive longitudinal study design, with follow-up every 3 months for 1 year.

SETTING

Three American Indian tribes in the Northern Plains.

SUBJECTS

Participants were 231 nonpregnant American Indian women.

INTERVENTION

Participants responded to drinking and contraception questions through the telephone and then received intervention materials via mail. Follow-up telephone surveys occurred at 3, 6, 9, and 12 months after the baseline call, and participants were again mailed intervention materials.

MEASURES

Alcohol consumption and birth control measurements were modified from the Project CHOICES program. The intervention was based on motivational interviewing constructs.

ANALYSIS

Analysis techniques included covariate-adjusted generalized estimating equation methods and Bonferroni correction.

RESULTS

All of the alcohol consumption amount responses had significant decreases with each follow-up intervention session; the average change for the range of questions was  -26% to -17%. The proportion of those stating they did not use birth control decreased from 29% to 10% during the first 3 months.

CONCLUSIONS

The intervention was successful in modifying self-reported drinking and contraception behaviors. This project is the only one to date that has focused on preventing alcohol-exposed pregnancies in nonpregnant American Indian women.

Characteristics and factors associated with the risk of a nicotine exposed pregnancy: expanding the CHOICES preconception counseling model to tobacco

The preconception counseling model tested in the CDC funded Project CHOICES efficacy trial to reduce the risk of an alcohol-exposed pregnancy (AEP) could be extended to smokers to prevent a nicotine-exposed pregnancy (NEP), when pharmacotherapy can be provided safely and disclosure of these risk behaviors is more likely. The CHOICES model, which incorporates motivational interviewing, encourages reduction of AEP risk by decreasing risky drinking or using effective contraception; in the efficacy trial, most women chose both options. We conducted a secondary analysis of the CHOICES epidemiologic survey data (N = 2,672) (Project CHOICES Research Group in Am J Prev Med 23(3), 166-173, 2002) to identify the prevalence of risk of NEP and the factors associated with this risk using logistic regression modeling procedures. Conducted in six settings with women at risk for AEP, the percentage of AEP was 12.5% (333/2,672) among women of childbearing age (18-44). A total of 464 of the 2,672 (17.4%) were at risk for NEP. Among women at-risk of an unplanned pregnancy (n = 1,532), the co-occurrence of AEP and NEP risk was more prevalent (16.3%) than AEP risk alone (5.5%) or NEP risk alone (14.0%). In the multivariable model, statistically significant correlates for NEP risk included lifetime drug use, prior alcohol/drug treatment, drug use in the last 6 months, being married or living with a partner, having multiple sexual partners in the last 6 months, physical abuse in the last year, and lower levels of education. These findings suggest that preconception counseling for NEP could be combined with a program targeting AEP.

Screening for use of alcohol, tobacco and cannabis in pregnancy using self-report tools

The World Health Organization has identified substance use in the top 20 risk factors for ill health. Risks in pregnancy are compounded, with risk to the woman's health, to pregnancy progression and on both the foetus and the newborn. Intrauterine exposure can result in negative influences on offspring development, sometimes into adulthood. With effectively two patients, there is a clear need for antenatal screening. Biomarker reliability is limited and research efforts have been directed to self-report tools, often attempting to address potential lack of veracity if women feel guilty about substance use and worried about possible stigmatization. Tools, which assume the behaviour, are likely to elicit more honest responses; querying pre-pregnancy use would likely have the same effect. Although veracity is heightened if substance use questions are embedded within health and social functioning questionnaires, such tools may be too lengthy clinically. It has been proposed that screening only for alcohol and tobacco, with focus on the month pre-pregnancy, could enable identification of all other substances. Alternatively, the Revised Fagerstrom Questionnaire could be used initially, tobacco being highly indicative of substance use generally. The ASSIST V.3.0 is readily administered and covers all substances, although the pregnancy 'risk level' cut-off for tobacco is not established. Alcohol tools - the 4Ps, TLFB and 'drug' CAGE (with E: query of use to avoid withdrawal) - have been studied with other substances and could be used. General psychosocial distress and mental ill-health often co-exist with substance use and identification of substance use needs to become legitimate practice for obstetric clinicians.

The effectiveness of a community-based intervention program for women at-risk for giving birth to a child with Fetal Alcohol Spectrum Disorder (FASD)

The goal of this study was to determine whether the First Steps program (modeled after the Parent-Child Assistance Program) resulted in improved outcomes among women at-risk for giving birth to a child with FASD. We conducted a retrospective analysis of data on 70 participants in the First Steps program. Clients were high risk and faced many life challenges, including: being on welfare, substance abuse, physical and sexual abuse as children, mental health issues, criminal activity, and unplanned pregnancies. We found a significant increase in birth control use and decrease in welfare rates from pre- to post-program. At program exit, many participants were abstinent from alcohol and/or drugs and the majority did not experience a subsequent pregnancy. Clients also showed significant increases in goals and decreases in needs from pre-to post-program. The First Steps program demonstrated promising outcomes for women at-risk for giving birth to a child with FASD.

Geographic and maternal characteristics associated with alcohol use in pregnancy

BACKGROUND

To date, no studies have used population-level data to investigate whether maternal location of residence (metropolitan vs. regional/remote populations) is associated with alcohol use in pregnancy. This information has important implications for appropriate service provision.

METHODS

Information on all live births in New South Wales, Australia, was linked to records of alcohol-related admissions for mothers of these births over a 6-year period (2000 to 2006). Cases were women who had at least 1 alcohol-related hospital admission during pregnancy or at birth. Controls were women who had at least 1 live birth over that same time period but no alcohol-related hospital admissions during that time. Admissions were considered to be alcohol-related based on the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM) code. Demographic, obstetric, and neonatal variables were compared.

RESULTS

A total of 417,464 singleton birth records were analyzed, 488 of which were coded positive for at least 1 alcohol-related ICD-10-AM diagnosis. Characteristics associated with alcohol-related admissions in pregnancy were residence in a remote/very remote area, being Australian-born, having had a previous pregnancy, smoking in the current pregnancy, and presenting late to antenatal care. Alcohol-exposed pregnancies were associated with a range of poor obstetric and neonatal outcomes, with no geographic differences noted. However, women in regional/remote areas were less likely to attend specialist obstetric hospitals.

CONCLUSIONS

This study shows the need for standardized screening programs for alcohol use in pregnancy and where problematic use is detected, for clear clinical guidelines on management and referral.

Motivational interviewing + feedback intervention to reduce alcohol-exposed pregnancy risk among college binge drinkers: determinants and patterns of response

Many college women are at risk for pregnancy, and binge drinking college women are often at risk for alcohol-exposed pregnancy. Brief interventions with sustainable outcomes are needed, particularly for college women who are binge drinking, at risk for pregnancy, and at increased risk of alcohol-exposed pregnancy. Two-hundred-twenty-eight women at a Mid-Atlantic urban university at risk for alcohol-exposed pregnancy enrolled in the randomized clinical trial, and 207 completed the 4 month follow-up. The BALANCE intervention used Motivational Interviewing plus feedback to target drinking and contraception behaviors. Main outcome measures included (1) the rate of risk for alcohol-exposed pregnancy, (2) the rate of risk drinking, and (3) the rate of pregnancy risk. At 4-month follow-up, the rate of alcohol-exposed pregnancy risk was significantly lower in the intervention (20.2%) than the control condition (34.9%), (P < .02). Assignment to the intervention condition halved the odds of women remaining at risk for alcohol-exposed pregnancy, while not receiving the intervention doubled the odds of continued alcohol-exposed pregnancy risk (OR = 2.18; 95% CI = 1.16-4.09). A baseline history of blackouts, continued high blood alcohol drinking days at 1 month, and continued risk for pregnancy at 1 month independently contributed to a multivariate model of continued alcohol-exposed pregnancy risk at 4 month follow-up. BALANCE reduced alcohol-exposed pregnancy risk, with similar outcomes to longer interventions. Because early response predicted sustained alcohol-exposed pregnancy risk reduction, those who fail to achieve initial change could be identified for further intervention. The BALANCE intervention could be adopted into existing student health or university alcohol programs. The risks of unintended pregnancy and alcohol-exposed pregnancy among binge drinking women in college merit greater prevention efforts.

Predictors of alcohol use prior to pregnancy recognition among township women in Cape Town, South Africa

South Africa has the highest prevalence of Fetal Alcohol Spectrum Disorders (FASDs) in the world. The purpose of this study was to identify high risk factors associated with drinking alcohol prior to pregnancy recognition in 24 neighborhoods in the Cape Flats outside Cape Town, South Africa. An interviewer assessed risk among 619 pregnant Black/African women between the ages of 18 and 41 years. Logistic regression analyses explored factors associated with drinking alcohol post conception but prior to pregnancy recognition. Forced multiple logistic regression analysis revealed that drinking prior to pregnancy recognition was associated with being younger, single, having better living conditions, smoking, having a longer gestation prior to pregnancy recognition, having a greater number of sexual partners, and a higher incidence of intimate partner violence. Depressive symptoms tended to be higher among alcohol users. These risk factors were consistent with other research on the characteristics of South African women having children with a diagnosis of Fetal Alcohol Spectrum Disorders and/or of non pregnant women at high risk for an alcohol-exposed pregnancy. These findings highlight the need for women of child-bearing age to be routinely screened for alcohol use and its associated risk factors. Intervention efforts could be integrated into health initiatives already present in South Africa including the prevention and treatment of HIV/AIDS, tuberculosis, and malnutrition. Preconception care is particularly important since pregnancy recognition often occurs several weeks to months following conception and could be implemented by South African community health workers. These endeavors should facilitate national goals of healthier pregnancies and the elimination of FASDs in South Africa.

Condom use among sterilized and nonsterilized women in county jail and residential treatment centers

PURPOSE

Although sterilized women do not need condoms for pregnancy prevention, they may still be at risk for sexually transmitted infections (STIs). Previous studies have shown that sterilized women have lower rates of condom use but have not controlled for the nested multilevel structure of data in which individual women have multiple partners with different STI risk factors. We address this limitation by testing the association of condom use and tubal ligation using multilevel analysis.

METHODS

Data were obtained from a cross-sectional survey of sterilized and nonsterilized women aged 18 to 44 in substance abuse treatment centers or county jail. Multilevel, random intercept logistic models examined the association of tubal ligation and any condom use in the 30 days before entry and controlled for individual- and partner-level correlates.

FINDINGS

Of 484 premenopausal respondents without hysterectomy, 194 (40.1%) reported tubal ligation. Overall, 48.4% of all women reported any condom use. In unadjusted and adjusted analyses, sterilized women were less likely to report any condom use. Women were least likely to use condoms with their main partners and more likely to use condoms with other partners and partners with whom they trade sex for drugs or money. Women were also more likely to use condoms if they are HIV positive or if they have partners they believe are HIV positive.

CONCLUSION

In these high-risk settings, we found a high prevalence of women reporting tubal ligation and lower odds of condom use among these women. Condom use interventions targeting sterilized women in these settings are needed.

A Dual-Focus Motivational Intervention to Reduce the Risk of Alcohol-Exposed Pregnancy

Project CHOICES developed an integrated behavioral intervention for prevention of prenatal alcohol exposure in women at high risk for alcohol-exposed pregnancies. Settings included primary care, university-hospital based obstetrical/gynecology practices, an urban jail, substance abuse treatment settings, and a media-recruited sample in three large cities. The intervention was based on motivational interviewing and targeted both adoption of effective contraception and reduction of alcohol use. Treatment included 4 manual-guided sessions delivered by mental health clinicians and 1 contraceptive counseling session delivered by a family planning clinician. This paper describes the rationale for treatment; the use of motivational interviewing and the transtheoretical model for a dual-focused approach to behavior change; the development of the Project CHOICES intervention; development of the study protocol and treatment manual; and selection, training, supervision, and monitoring of study counselors. Implications for future applications of the intervention are discussed.

Beyond behavior: eliciting broader change with motivational interviewing

Descriptions of Motivational interviewing (MI) usually focus on helping clients change a single problematic behavior. In contrast, the current case study shows that MI can serve as a more comprehensive psychotherapy, focused not only on multiple problem behaviors but also on broader change consistent with its roots in client-centered therapy. In this case, the therapist interwove a focus on several discrete behaviors with a focus on broader lifestyle change as well as increased clarity of client cognitions, values, and choices, resulting in several lasting changes.

Toward prevention of alcohol exposed pregnancies: characteristics that relate to ineffective contraception and risky drinking

Alcohol-exposed pregnancy is a leading cause of preventable birth defects in the United States. This paper describes the motivational patterns that relate to risky drinking and ineffective contraception, two behaviors that can result in alcohol-exposed pregnancy. As part of an intervention study aimed at reducing alcohol-exposed pregnancy 124 women were recruited and reported demographic characteristics, readiness to change, stages of change, drinking, contraception, and sexual behavior history. Our results showed the following. Drinking: A significant positive correlation was found between the number of drinks consumed in 90 days and the Importance to reduce drinking (r = .23, p = .008). A significant negative correlation between number of drinks and confidence to reduce drinking (r = -.39, p = .000) was found as well. Significant differences were found in the total number of drinks consumed in 90 days between the five stages of change (F = (4,118), 3.12, p = .01). Women in Preparation reported drinking a significantly higher number of drinks than women in other stages of change. Contraception: There were significant negative correlations between ineffective contraception and Importance (r = -.38, p = .00), confidence (r = -.20, p = .02) and Readiness (r = -.43, p = .00) to use contraception effectively. Significant differences in contraception ineffectiveness were found for women in different stages of change (F = (4,115) 8.58, p = .000). Women in Precontemplation reported significantly higher levels of contraception ineffectiveness compared to women in other stages of change. Results show a clear relationship between higher alcohol consumption and higher levels of motivation to reduce drinking. In contrast, higher levels of ineffective contraception were related to lower levels of motivation to use contraception effectively. This suggests risky drinking may be better targeted with brief skills building interventions and ineffective contraception may require interventions that enhance problem awareness and motivation.

A Quick Drinking Screen for identifying women at risk for an alcohol-exposed pregnancy

Two previous studies comparing the Quick Drinking Screen (QDS) with the Timeline Followback (TLFB) found that these two instruments yielded similar reports of alcohol use for clinical and nonclinical populations of problem drinkers. The current study evaluated the correspondence between these two drinking measures with women at risk of an Alcohol-Exposed Pregnancy (AEP). Participants were 355 women who voluntarily participated in a research study during 2005 through 2007 designed to prevent AEPs. All women were screened by phone for eligibility using the QDS and approximately 2 weeks later completed a 3-month TLFB by mail. Results of this study, analyzed in 2008, paralleled previous studies showing that the QDS and the TLFB, two very different drinking measures, collected similar aggregate drinking data for women who drink heavily and are at risk of an AEP. Correspondence between the two drinking measures met acceptable levels of reliability. The present study found that the QDS has demonstrated efficacy for screening women whose level of alcohol use puts them at risk for an AEP. Although the QDS does not yield detailed drinking information, it could be used when it is not possible or necessary to gather daily drinking data.

Risk of alcohol-exposed pregnancies among low-income, illicit drug-using women

OBJECTIVES

Poor women of childbearing age who use crack, cocaine, marijuana, and heroin may be at risk for having an alcohol-exposed pregnancy because of concurrent alcohol use. Women who use illicit drugs may not know the harmful effects of fetal alcohol exposure. Fetal alcohol exposure is a leading cause of developmental disabilities and mental retardation.

METHODS

We report findings of a survey administered to 2672 women 18-44 years of age in settings serving low-income women, including an urban jail, a drug treatment facility, and healthcare facilities in Florida, Virginia, and Texas. We compared women who reported using more than one illicit drug (drug users) and women who reported never using illicit drugs (nonusers) for frequent alcohol consumption, binge drinking, failure to use contraception, unplanned pregnancies, and drinking during pregnancy.

RESULTS

Of women interviewed, 75% (2000) reported using more than one illicit drug. Drug users were more likely to report frequent drinking (33%, relative risk [RR] 12.73, 95% confidence interval [CI] 7.9-20.4, binge drinking (39%, RR 5.7, 95% CI 4.9-7.6), and drinking during pregnancy (37%, RR 2.10, 95% CI 1.75-2.53) compared with nonusers (3%, 7%, 17%, respectively, p < 0.0001). Greater proportions of drug users (27%, RR 2.20, 95% CI 1.75-2.53) also failed to used contraception compared with nonusers (19%, p < 0.05). Notable proportions of both groups, drug users (91%) and nonusers (82%), reported unplanned pregnancies.

CONCLUSIONS

The findings suggest that poor women who reported ever using more than one illicit drug were at greater risk for having an alcohol-exposed pregnancy. Unplanned pregnancies in both groups surpassed national averages. Poor women likely require enhanced education about the hazards of drinking during pregnancy and methods to reduce unplanned pregnancies.

History of physical abuse and periconceptional drinking in pregnant women

This study examines the relationship between physical abuse and periconceptional drinking in women presenting to a mid-Atlantic, urban hospital-based OB/GYN clinic serving a largely indigent population between April 2003 and May 2004. During their first prenatal visit, 308 women completed a screening battery that included the Abuse Assessment Screen (AAS) and measures of alcohol use, including the CAGE, T-ACE, TWEAK, and the PRIME-MD Patient Health Questionnaire (PHQ). Bivariate analyses, including odds ratios (ORs) and 95% confidence intervals (CIs), revealed that women with a history of physical abuse were more likely to report drinking alcohol within the 3 months prior to their prenatal care visit and were significantly more likely to meet criteria for risk drinking on multiple measures. A history of physical abuse appears to be associated with higher self-reported rates of periconceptional drinking in pregnant women. Study findings support the need for assessment of abuse history as a potential risk factor for alcohol use in pregnant women.

Exploring pregnancy-related changes in alcohol consumption between black and white women

BACKGROUND

Although epidemiological data indicate that White women are more likely to drink and binge drink before pregnancy, fetal alcohol syndrome (FAS) is more common in the Black population than among Whites in the United States. Differences in drinking cessation between Black and White women who become pregnant may help explain the disparity in FAS rates.

METHODS

The study sample was comprised of 280,126 non-Hispanic Black and White women, ages 18 to 44, from the Behavioral Risk Factor Surveillance System (BRFSS) 2001 to 2005 data sets. Predictors of reduction in alcohol consumption (in drinks per month) and binge drinking (>4 drinks on one occasion) by pregnant and non-pregnant women were identified with logistic regression. The effect of interactions of pregnancy status with age, education, and Black or White race on drinks per month and binge occasions were explored using analysis of variance (ANOVA).

RESULTS

Pregnant White women averaged 79.5% fewer drinks per month than non-pregnant White women (F = 1250.1, p < 0.001), and 85.4% fewer binge drinking occasions (F = 376, p < 0.001). Pregnant Black women averaged 58.2% fewer drinks per month than non-pregnant Black women (F = 31.8, p < 0.001) and 64.0% fewer binge occasions (F = 13.8, p < 0.001). Compared to Black women, White women appear to make a 38% greater reduction in drinks per month, and a 33% greater reduction in binge occasions.

CONCLUSIONS

Non-Hispanic White women appear more likely to reduce drinks per month and binge drinking occasions than non-Hispanic Black women during pregnancy. These findings may help explain disparities in FAS in the United States, though this cross-sectional sample does not permit claims of causation. To better describe the impact of differential drinking reduction on FAS rates, future studies of longitudinal data should be done.

Psychiatric Distress in Incarcerated Women With Recent Cocaine and Alcohol Abuse

PURPOSE

Women frequently abuse cocaine and alcohol before incarceration. Research indicates that women in criminal justice settings also suffer high rates of psychiatric distress. This study aimed to determine how preincarceration abuse of alcohol and cocaine affected current psychiatric distress among female jail detainees held for 10-14 days.

METHODS

A probability sample of women in a large urban jail (n = 469) were assessed for use of alcohol and cocaine during the 6 months before incarceration and for their current psychiatric distress. They were grouped based on their level of alcohol consumption and cocaine use: high cocaine/high alcohol; high cocaine/low alcohol; low cocaine/high alcohol; and low cocaine/low alcohol. Profile analysis was used to examine the relation of psychiatric distress, as measured by the Brief Symptom Inventory, to levels of recent alcohol and cocaine use.

RESULTS

Psychiatric distress is highest (and similar) among women in the high cocaine groups, regardless of alcohol use, and psychiatric distress is lowest among those who used both substances infrequently. Characteristics of psychiatric distress differed based on level of alcohol use, but only when cocaine use was low. High alcohol and cocaine use alone and together also predict the likelihood of psychiatric distress reaching a diagnosable level of severity.

CONCLUSIONS

High cocaine, alcohol, or combined use is related to higher levels of psychiatric distress among incarcerated women in this jail. Women should be screened at the time of incarceration, and women who have alcohol and other drug problems should receive treatment that includes mental health services.

Preventing alcohol-exposed pregnancies: a randomized controlled trial

BACKGROUND

Prenatal alcohol exposure is a leading preventable cause of birth defects and developmental disabilities in the United States.

DESIGN

A randomized controlled trial (2002-2005; data analyzed 2005-2006) of a brief motivational intervention to reduce the risk of an alcohol-exposed pregnancy (AEP) in preconceptional women by focusing on both risk drinking and ineffective contraception use.

SETTING/PARTICIPANTS

A total of 830 nonpregnant women, aged 18-44 years, and currently at risk for an AEP were recruited in six diverse settings in Florida, Texas, and Virginia. Combined settings had higher proportions of women at risk for AEP (12.5% overall) than in the general population (2%).

INTERVENTIONS

Participants were randomized to receive information plus a brief motivational intervention (n=416) or to receive information only (n=414). The brief motivational intervention consisted of four counseling sessions and one contraception consultation and services visit.

MAIN OUTCOME MEASURES

Women consuming more than five drinks on any day or more than eight drinks per week on average, were considered risk drinkers; women who had intercourse without effective contraception were considered at risk of pregnancy. Reversing either or both risk conditions resulted in reduced risk of an AEP.

RESULTS

Across the follow-up period, the odds ratios (ORs) of being at reduced risk for AEP were twofold greater in the intervention group: 3 months, 2.31 (95% confidence interval [CI]=1.69-3.20); 6 months, 2.15 (CI=1.52-3.06); 9 months, 2.11 (CI=1.47-3.03). Between-groups differences by time phase were 18.0%, 17.0%, and 14. 8%, respectively.

CONCLUSIONS

A brief motivational intervention can reduce the risk of an AEP.

Changes in the Prevalence of Alcohol Use during Pregnancy among Recent and At-Risk Drinkers in the NLSY Cohort

PURPOSE

To support efforts to prevent fetal alcohol syndrome (FAS), population-based data are needed on the prevalence of alcohol use at any time during gestation, particularly among women who were recent and at-risk drinkers.

METHODS

We used National Longitudinal Survey of Labor Market Experiences in Youth (NLSY) files to estimate the prevalence of any drinking during pregnancy and to evaluate alcohol history risk factors among 6676 births reported by women with prepregnancy drinking data. Prevalence estimates were obtained for 2-year intervals for all 1982-1995 births and for subsets with prepregnancy recent and at-risk drinking.

RESULTS

Among all births, drinking during pregnancy declined from 38.3% in 1982-1983 to 23.0% in 1994-1995 (p < 0.0001). Drinking during pregnancy also declined over time among recent and at-risk drinkers (p < 0.0001), but the 1994-1995 prevalences were still high (39.3% and 29.0%, respectively). Adjusted logistic models confirmed both the decrease in risk for the later birth years and the persistent heightened risk for births among recent and at-risk drinkers.

CONCLUSIONS

In addition to ongoing universal prevention strategies that have helped reduce the prevalence of drinking during pregnancy, selective and indicated prevention approaches are needed to encourage abstinence during pregnancy among recent and at-risk drinkers.

Pediatricians' knowledge, training, and experience in the care of children with fetal alcohol syndrome

OBJECTIVES

Prenatal exposure to alcohol interferes with fetal development and is the leading preventable cause of birth defects and developmental disabilities. The purpose of this study was to identify current knowledge, diagnosis, prevention, and intervention practices related to fetal alcohol syndrome and related conditions by members of the American Academy of Pediatrics.

METHODS

This study was developed collaboratively by the American Academy of Pediatrics and the Centers for Disease Control and Prevention. Questionnaires were mailed to a 3% random sample (n = 1600) of American Academy of Pediatrics members in the United States. General pediatricians, pediatric subspecialists, and pediatric residents were included.

RESULTS

Participation rate was 55% (n = 879). Respondents almost universally knew the teratology and clinical presentation of fetal alcohol spectrum disorders. However, they were less likely to report comfort with routine pediatric care of these children. Whereas 62% felt prepared to identify and 50% felt prepared to diagnose, only 34% felt prepared to manage and coordinate the treatment of children with fetal alcohol spectrum disorders. Even fewer (n = 114 [13%]) reported that they routinely counsel adolescent patients about the risks of drinking and pregnancy.

CONCLUSIONS

The survey confirms that pediatricians are knowledgeable about fetal alcohol syndrome but do not feel adequately trained to integrate the management of this diagnosis or prevention efforts into everyday practice. Furthermore, the respondents were not active in routine anticipatory guidance with adolescents for prevention of alcohol-affected pregnancies. The development, dissemination, and implementation of best practice tools for prevention, diagnosis, and referral of fetal alcohol syndrome that are specific for general and subspecialist pediatricians are recommended.

Reducing alcohol-exposed pregnancy risk in college women: initial outcomes of a clinical trial of a motivational intervention

A significant number of college women are at risk for alcohol-exposed pregnancy (AEP) owing to binge drinking paired with using contraception ineffectively. This article describes a randomized controlled trial of a one-session motivational interviewing-based intervention to reduce AEP risk among college women and presents 1-month outcomes demonstrating the early impact of this intervention. There were 228 female students from a mid-Atlantic urban university enrolled in the trial. Eligibility criteria were being in the age range of 18-24 years and being at risk for AEP. Risk for AEP was defined as having sexual intercourse with a man in the past 90 days while using contraception ineffectively (no use, incorrect use of an effective method, or use of an ineffective method only); drinking at risky levels was defined as engaging in at least one binge in the past 90 days or consuming an average of eight standard drinks per week. One-month outcome data were available for 212 of the 228 enrolled women (a follow-up rate of 93%), with complete data available for 105 women assigned to the control condition and 94 assigned to the intervention condition. At 1-month follow-up, 15% of the control subjects and 25% of the intervention women reported no risk drinking, a significant difference favoring the intervention group. Significantly fewer control subjects (48%) used effective contraception at 1-month follow-up as compared with intervention women (64%), chi(2)(1) = 5.1, p < .03. Significantly more intervention women (74%) were no longer at risk for AEP at 1 month as compared with control subjects (54%), chi(2)(1) = 8.15, p < .005. Factors that were associated with continued AEP risk at 1-month follow-up were a higher number of standard drinks per day consumed in the month prior to baseline (odds ratio, 1.1) and assignment to the control condition (odds ratio, 2.9). The risks of unintended pregnancy and AEP among drinking women in college merit greater prevention efforts. The results of this study show the promise of one preventive intervention that warrants additional study.

Characteristics of adult women who abstain from sexual intercourse

OBJECTIVES

To evaluate demographic and behavioural characteristics of sexually active women compared to those who had abstained from intercourse in the past 6 months.

METHODS

The study participants were women of childbearing age from six sites in three states in the USA. Survey questions were asked of women who were not surgically sterile and who had not gone through menopause. The main outcome measures were correlates of sexual abstinence.

RESULTS

Of the 1801 respondents, 244 (14%) reported abstaining from intercourse in the past 6 months. Univariate analysis revealed that abstinent women were less likely than sexually active women to have used illicit drugs [odds ratio (OR) 0.47; 95% CI 0.35-0.63], to have been physically abused (OR 0.44, 95% CI 0.31-0.64), to be current smokers (OR 0.59, 95% CI 0.45-0.78), to drink above risk thresholds (OR 0.66, 95% CI 0.49-0.90), to have high Mental Health Inventory-5 scores (OR 0.7, 95% CI 0.54-0.92) and to have health insurance (OR 0.74, 95% CI 0.56-0.98). Abstinent women were more likely to be aged over 30 years (OR 1.98, 95% CI 1.51-2.61) and to have a high school education (OR 1.38, 95% CI 1.01-1.89). Logistic regression showed that age >30 years, absence of illicit drug use, absence of physical abuse and lack of health insurance were independently associated with sexual abstinence.

CONCLUSIONS

Prolonged sexual abstinence was not uncommon among adult women. Periodic, voluntary sexual abstinence was associated with positive health behaviours, implying that abstinence was not a random event. Future studies should address whether abstinence has a causal role in promoting healthy behaviours or whether women with a healthy lifestyle are more likely to choose abstinence.

Monitoring prenatal alcohol exposure

Alcohol use during pregnancy is a leading, preventable cause of birth defects and developmental disabilities in the United States, with fetal alcohol syndrome (FAS) being one of the most severe outcomes. Current survey statistics find that approximately one in eight pregnant women (500,000 per year) report alcohol use, with approximately 80,000 reporting binge drinking. While annual rates have fluctuated, trends analysis finds that there has been no significant change in rates of prenatal alcohol exposure over the past 10-year period. Development of effective programs to prevent FAS and to monitor the success of prevention efforts requires epidemiological data systems to inform these activities. This article describes alcohol use patterns among childbearing-age women and data sources that can be used in monitoring this behavior.

Jails as important but constrained venues for addressing women's health

Women in US jails have many social and health risks that merit attention from public health agencies. This article: (1) reviews national and local data on this population for indicators of social disadvantage and of several health risks/conditions (substance abuse, risky sex, and mental illness), (2) describes the impact of federal mandatory sentencing for drug violations and recent developments in states on the numbers of incarcerated women, (3) outlines the similarities and differences between jails and prisons, focusing on characteristics of jails that facilitate and constrain intervention and evaluation activities, and (4) adds lessons learned in six years of experience in county and state jails in Texas.