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Position Statement

Prevention of Alcohol-Exposed

he National Association of Nurse Prac - ports repeal of existing laws with such mandates. tTitioners in Women’s Health (NPWH) supports NPWH will provide leadership and collaborate women’s health nurse practitioners (WHNPs) and with other organizations and agencies to deliver other nurse practitioners (NPs) who provide health - education and skills training for NPs, develop poli - care for reproductive-aged women in the use of cies, and conduct and/or support research in a evidence-based strategies to prevent alcohol- concerted effort to prevent AEP. exposed pregnancies (AEP). Use of these strategies should extend to alcohol screening at least yearly Background for all adolescent and adult patients. In addition, Prenatal alcohol exposure is the No. 1 preventable all sexually active, reproductive-aged women who cause of defects and intellectual and devel - could become pregnant and who drink alcohol opmental disabilities in children. Alcohol, a known should be counseled about the potentially deleteri - teratogen, readily crosses the and per - ous effects of alcohol on a developing . They sists in amniotic fluid after a woman’s serum alco - should be advised to use effective contraception hol level metabolizes to zero. Toxicity is dose re - to prevent or to stop drinking alcohol. lated, with the greatest risk to the fetus in the first Women who are trying to get pregnant should be trimester. 4 With regard to preventing fetal alcohol advised to abstain from drinking alcohol. Pregnant spectrum disorders (FASD) and other adverse women should be screened for alcohol use at their pregnancy and birth outcomes associated with initial prenatal visit and during each trimester prenatal alcohol exposure, there is no known safe thereafter. 1 For those who screen positive for risky amount of alcohol use at any time during pregnancy . alcohol use, NPs should provide a brief behavioral FASD is an umbrella term describing a range of intervention, refer them to specialty services as possible effects that include physical, intellectual, needed, and plan appropriate follow-up. behavioral, and learning disabilities and language Furthermore, NPWH recognizes that early and delays, with lifelong implications for individuals regular for women with alcohol de - prenatally exposed to alcohol. 5 FASD are com - pendence is essential in order to encourage healthy pletely preventable if alcohol is not consumed dur - behaviors and provide support and early treatment ing pregnancy. But many pregnant women do referrals to reduce risks of harm. Laws that require drink alcohol; the estimated prevalence of FASD in reporting of alcohol/substance abuse during preg - first-grade students in the United States is 2%-5%. 6 nancy as potential child abuse or ne glect may deter The lifetime cost of caring for an with fetal al - women with alcohol dependence from seeking cohol syndrome, a single disorder within the FASD prenatal care. 2,3 Therefore, NPWH opposes policies continuum, is approximately $2 million. 7 In addi - that require reporting or criminalization of alco - tion to FASD, alcohol use during pregnancy is asso - hol/substance abuse during pregnancy and sup - ciated with increased risks for spontaneous abor -

505 C Street, NE Washington, DC 20002-5809 P: 202.543.9693 F: 202.543.9858 npwh.org ● ● ● ● 18 November 2016 Women’s Healthcare NP WOMENS HEALTHCARE .com tion, intrauterine growth restriction, stillbirth, has symptoms of dependency. If at-risk drinking is , and sudden infant death syndrome. 8 identified, the NP engages the woman in a brief In 2005, the U.S. Surgeon General advised that motivation-enhancing intervention to reduce pregnant women not drink any alcohol, pregnant drinking. The main goal of alcohol SBI is to moti - women who have already consumed alcohol stop vate patients to be aware of their alcohol con - doing so, and women considering becoming preg - sumption patterns, understand the associated nant abstain from drinking alcohol. 9 Despite this risks and options for reducing or eliminating the recommendation, the number of women who risk, and make their own decisions. Referral to spe - drink alcohol while pregnant has not decreased cialty care for further assessment and treatment is significantly. 10 Ten percent of pregnant women re - made if a woman is unable to moderate risky alco - port drinking some amount of alcohol in the past hol use on her own. The CDC’s Planning and Im - month and 3.1% report binge drinking. 10 plementing Screening and Brief Intervention for The fact that about one-half of all pregnancies Risky Alcohol Use: A Step-by-Step Guide for are unplanned poses a particular challenge to the Primary Care Practices A provides guidance for prevention of AEP. Approximately 3.3 million re - incorporating universal alcohol SBI within clinical productive-aged women report drinking alcohol practice. 7 This guide includes information on the in the past month and having sex without using use of a variety of screening tools validated for use contraception. 11 An additional challenge is that with adults, including pregnant women. only 1 in 6 U.S. adults reports ever having talked WHNPs and other NPs who provide healthcare with a healthcare professional about their drink - for reproductive-aged women have a responsibil - ing. 11 Therefore, many adults may be unaware of ity to provide clear, fact-based information regard - the potential risks of alcohol use to their own ing risks associated with drinking any amount of health or to the health of a developing fetus. alcohol during pregnancy. Furthermore, they have the responsibility to identify women with at-risk Implications for women’s healthcare drinking habits and provide counseling and refer - and WHNP practice rals for treatment as appropriate. Strong evidence suggests that alcohol screen - ing and brief intervention (SBI) is effective in re - Recommendations ducing risky alcohol use among women of WHNPs and other NPs who provide healthcare childbearing age. 12,13 Leading U.S. healthcare for reproductive-aged women should: organizations and agencies, including the U.S. • Adopt a non-judgmental respectful approach Preventive Services Task Force, 14 the CDC, 11 and when broaching the topic of alcohol use. the American College of Obstetricians and • Counsel each reproductive-aged woman in Gyne cologists, 15 recommend that alcohol SBI their care that there is no safe amount of alco - be implemented at least yearly for all adults in hol consumption during pregnancy and pro - primary care settings. Likewise, all pregnant vide fact-based information regarding risks. women should be screened at the first prenatal • Provide alcohol screening with a validated visit and once during each trimester thereafter. screening tool annually and during each Alcohol SBI involves using a validated screening trimester of pregnancy. tool to identify a woman’s drinking patterns, • Provide an evidence-based brief intervention whether her alcohol consumption is creating a when at-risk alcohol use is identified. health risk for herself or others, and whether she • Advise all pregnant women who drink alcohol

505 C Street, NE Washington, DC 20002-5809 P: 202.543.9693 F: 202.543.9858 npwh.org ● ● ● ● NP WOMENS HEALTHCARE .com November 2016 Women’s Healthcare 19 to stop doing so. 4. Mattison DR, ed. Clinical Pharmacology During Pregnancy . Amsterdam: Academic Press, an Imprint of • Advise all women planning a pregnancy who Elsevier; 2013. drink alcohol to stop doing so. 5. Sokel RJ, Delaney-Black V, Nordstrom B. Fetal alco - • Advise all sexually active women who drink al - hol spectrum disorder. JAMA . 2003;290(22):2996-2999. cohol and could become pregnant to use effec - 6. May PA, Baete A, Russo J, et al. Prevalence and tive contraception to prevent pregnancy or to characteristics of fetal alcohol spectrum disorders. Pedi - atrics . 2014;134(5):855-866. stop drinking. 7. CDC. Planning and Implementing Screening and • Recognize that not all women are able to stop Brief Intervention for Risky Alcohol Use: A Step-by-Step using alcohol without support. Guide for Primary Care Practices . Atlanta, GA: CDC Na - tional Center on Birth Defects and Developmental Dis - • Refer women for additional services if they can - abilities; 2014. not stop drinking on their own. Know which 8. Bailey BA, Sokol RJ. Prenatal alcohol exposure and services are available in the community. , stillbirth, preterm delivery, and sudden infant • Provide follow-up as needed to monitor women’s death syndrome. Alcohol Res Health . 2011;34(1):86-91. drinking, provide encouragement and support, 9. U.S. Department of Health and Human Services. U.S. Surgeon General Releases Advisory on Alcohol Use and, if necessary, refer for specialized help. in Pregnancy . Washington, DC: US Department of • Be aware of state reporting laws for alcohol/sub - Health and Human Services; 2005. stance abuse in pregnancy and advocate for re - 10. Tan CH, Denny CH, Cheal NE, et al. Alcohol use traction of legislation that exposes pregnant and binge drinking among women of childbearing age - United States, 2011-2013. MMWR Morb Mortal Wkly women with alcohol dependence to criminal or Rep . 2015;64(37):1042-1046. civil penalties. 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; NPWH will provide leadership and resources to 65(4):91-97. ensure that: 12. Bertholet N, Daeppen JB, Wietlisbach V, et al. Re - • Educational programs for NP students with a duction in alcohol consumption by brief alcohol inter - population focus that includes reproductive- vention in primary care: systematic review and meta- analysis. Arch Intern Med . 2005;165(9):986-995. aged women impart evidence-based knowledge 13. Jonas DE, Garbutt JC, Amick HR, et al. Behavioral and skill building for the development of compe - counseling after screening for alcohol misuse in pri - tencies to conduct effective alcohol SBI to pre - mary care: a systematic review and meta-analysis for vent or address alcohol use during pregnancy. the U.S. Preventive Services Task Force. Ann Intern Med . 2012;157(9):645-654. • CE programs are available for NPs to obtain evi - 14. Moyer VA; Preventive Services Task Force. Screen - dence-based knowledge and competencies to ing and behavioral counseling interventions in primary conduct effective alcohol SBI to prevent or ad - care to reduce alcohol misuse: U.S. preventive services dress alcohol use during pregnancy. task force recommendation statement. Ann Intern Med . = 2013;159(3):210-218. References 15. ACOG. Committee on Health Care for Underserved 1. Nocon J. Chapter 15: Substance use disorders. In Mat - Women. Com mittee opinion no. 496: At-risk drinking tison DR, ed. Clinical Pharmacology During Pregnancy . and alcohol dependence: obstetric and gynecologic im - Amsterdam: Academic Press, an Imprint of Elsevier; 2013. plications. Obstet Gynecol . 2011;118(2 pt 1):383-388. Reaffirmed 2013. 2. ACOG. Committee on Health Care for Underserved Women. Committee opinion no. 473: Substance abuse reporting and pregnancy: the role of the obstetrician- Web resource gynecologist. Obstet Gynecol . 2011;117(1):200-201. Reaf - A. cdc.gov/ncbddd/fasd/documents/alcoholsbiimplementa - firmed 2014. tionguide.pdf 3. Guttmacher Institute. Substance Abuse During Pregnancy . Washington, DC: Author; 2014. Approved by the NPWH Board of Directors: August 2016

505 C Street, NE Washington, DC 20002-5809 P: 202.543.9693 F: 202.543.9858 npwh.org ● ● ● ● 20 November 2016 Women’s Healthcare NP WOMENS HEALTHCARE .com