Updated: Nov 22, 2021
Clinicians are likely largely naive to the prominence of #alcohol among their primary care clients, particularly #maternity clients. Not only will this be a missed opportunity to discuss the risks of drunk-driving, sexual assaults, unplanned pregnancy and injuries, but also, health risks such as cardiovascular injury and injury to the liver and other organs, including one's brain. While these conversations can be incredibly tough, not initiating this conversation eliminates opportunity to make a difference that can last a lifetime.
The National Association of Nurse Practitioners in Women's Health, the American College of Obstetricians and Gynecologists, the CDC, and the U.S. Preventive Services Task Force all recommend that #screening for at-risk alcohol use occur, at least annually, for all adults in primary care settings. Pregnant women should be screened at the first prenatal visit and then once each trimester thereafter. The primary goal with these screenings is to assist the client in having some mindfulness in their alcohol consumption and to gain some understanding of their options for reducing or eliminating risks.
Midwives and other primary or maternity care providers are encouraged to ask clients about their #alcohol use. Validated screening tools are available to identify drinking patterns which can help ascertain whether their alcohol consumption is creating health risks for themselves or others, or if they have symptoms of dependency. If risk is identified for dependence, then a discussion can happen regarding strategies for reducing drinking. It the client is unable to modify their alcohol risk on their own, then a referral to specialty care can be provided.
Screening for Alcohol Dependency
The CDC recommends using one of the two tools for a brief alcohol screen, either the Single Question Alcohol screen or the AUDIT 1-3. Each measure quantity of drinks consumed, and both identify one standard drink as 12 ounces of beer or a wine cooler, 5 ounces of table wine, or a 1.5-ounce shot of 80-proof spirits such as whiskey, gin, or vodka. These screenings are for the primary care provider to identify risk and then to open up opportunity to discuss readiness for implementing healthier options. Here is a more thorough guide to help the practitioner implement screening into their practice model.
There is no known safe amount of alcohol to use at any time during pregnancy, so any consumption at all is considered a risk in pregnancy. Alcohol is a known teratogen (toxen leading to damage to the unborn child) and readily crosses the placenta. Alcohol exposure to the fetus is the number one preventable cause of birth defects and intellectual and developmental disabilities in children.
Alcohol & Pregnancy
Alcohol is a potential physical and behavioral teratogen, meaning it can alter the fetal cells or kill them entirely. This can result in physical changes to the fetus, that can be identified immediately, or behavioral and developmental changes, which may take years to fully realize. The significance of this can't be reliably predicted, as there is no amount of alcohol that has demonstrated no effect on the fetus. Here is a handout offering further details about fetal alcohol syndrome.
Alcohol is so commonplace in American culture, that it is imbibed while people socialize with friends, relax after work, enjoyed at romantic dinners, and while attending celebrations. "The ubiquity of the experience can lead to ambivalence about changing one's drinking habits, even when these habits may be harmful," (Kelsey & Pierce-Bulger, 2017, p 40).
Drinking is a rite of passage for teenagers or early adults. It is often used as a way to self-medicate, particularly in those who suffer with anxiety and depression. Its misuse and abuse can be a bit stigmatizing, so often those who have heavier use begin to hide their habit. This can be especially troublesome, but common, in pregnancy.
Those who abuse alcohol span all races, religions, ethnicities, economic statuses, educational backgrounds, and even presentation. Many are what we call "functioning alcoholics," so their ability to maintain a successful lifestyle can be misleading, to themselves and their practitioners. Healthcare providers should make no assumptions about their clients and who may be drinking alcohol in pregnancy.
One in nine women report binge drinking during their first trimester of pregnancy. One in five women report drinking during the first trimester. Between 0.5 and two live births, of every 1000 births, the infant is born with fetal alcohol syndrome. An estimated 40K children are born each year with fetal alcohol syndrome, and it is estimated that more than half go undiagnosed. The cost to our country's citizens to care for these children, is estimated at about $6 billion per year.
Fetal Alcohol Syndrome
A child with fetal alcohol syndrome (FAS) may not develop an IQ beyond 60 which is considered "educable retardation" in the United States. This syndrome was first recognized in the 1960s but became particularly well known in the mid-70s. One of the key issues with FAS is the damage is largely done in the first trimester, before many women even know they are pregnant.
Research is challenged by the ethical inability to randomize women into groups who drink and those who don't to determine what amount and women, alcohol may be safe in pregnancy; therefore, there is no known safe amount of alcohol during pregnancy. Self-reporting is also quite undependable.
One of the key signs of a child with FAS is the low birth weight when compared to children who have reached the same gestational age. A smaller skull size is also associated with FAS. They may appear healthy to family and friends, but a these two findings are significant for FAS. As the child grows, their overall height will be shorter than other children and this lag is never resolved.
Some facial anomalies are also present, such as smaller or shorter eye sockets, absence or noticeable smoothing of the philtrum (crease between the upper lip and nose), and flattened cheekbones. Motor delays may result. Sitting and walking may be delayed. Vocabulary may be limited. In more severe cases, other diseases may seem more appropriate, such as spina bifida, hydrocephalus, cleft lip, or narrowing of the aorta heart valve.
Any person drinking more than either the daily or weekly levels mentioned here, are drinking too much. If a person exceeds weekly levels, a long-term risk for a wide range of chronic conditions becomes likely. If one exceeds the single-day levels, he or she risks intoxication, which is associated with a variety of more immediate risks.
Healthy men ages 21-65 years are deemed at risk when drinking more than 4 drinks on any single day and five or more drinks consumed within 2 hours is binge drinking. Keep in mind, this includes a beer, glass of wine, or a single shot. More than 14 drinks in total a week would also be considered risky for this group. Men over 65 years and women, 21 years and older, drinking more than 3 drinks on any single day or 4 or more drinks within two hours (binge) are at risk, or if they drink more than 7 drinks a week.
For some, even less is risky. Anyone taking prescription medications or over-the-counter medications that interact with alcohol can cause harmful reactions. Various medical conditions can make drinking even more dangerous, even at lower doses. Liver disease, elevated cholesterol, pancreatitis, cardiac disease, and even mental health disorders are among these. Those who drive, plan to drive, or participate in other activities requiring skill, coordination, and alertness.
There are individuals who are at risk with any level of exposure to alcohol as well. Those who are unable to control the amount they drink, women who are pregnant or might become pregnant, or individuals younger than 21 years of age.
Kelsey, B. K. & Pierce-Bulger, M. (2017). Having the conversation about alcohol as a teratogen: three women. Women's Healthcare, 36-40.