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Alcohol-Screening Instruments for Pregnant Women Alcohol-Screening Instruments for Pregnant Women Grace Chang, M.D., M.P.H. According to new studies, even low levels of prenatal alcohol exposure can negatively affect the developing fetus, thereby increasing the importance of identifying women who drink during pregnancy. In response, researchers have developed several simple alcohol-screening instruments for use with pregnant women. These instruments, which can be administered quickly and easily, have been evaluated and found to be effective. Because of the potential adverse consequences of prenatal alcohol exposure, short screening questionnaires are worthwhile preventive measures when combined with appropriate followup. KEY WORDS: prenatal alcohol exposure; prenatal diagnosis; alcohol use test; identification and screening for AOD (alcohol or other drug) use; specificity and sensitivity of measurement; breath alcohol analysis; AODR (alcohol- or other drug-related) biological markers creening pregnant women for five or more drinks per occasion) by 3.5 drinks per week) demonstrated that alcohol use has become of increasing pregnant women has increased substan­ the women who drank more than 3.0 Simportance, because new research tially, from 0.8 percent in 1991 to 3.5 drinks per week increased significantly indicates that even low levels of prenatal percent in 1995 (Ebrahim et al. 1998; their risk of first-trimester spontaneous alcohol exposure can negatively affect Centers for Disease Control and abortion (Windham et al. 1997). the developing fetus. Adverse effects of Prevention 1997). This rise in the rate Identifying women who drink at prenatal alcohol exposure can range from of alcohol consumption among pregnant risky levels during pregnancy poses spe­ subtle developmental problems, or fetal women coincides with growing evidence cial challenges, however, particularly alcohol effects, to full-blown fetal alcohol of the negative effects of low-to-moderate because the definition of pregnancy risk syndrome. In addition, scientists and alcohol consumption during pregnancy. drinking has been refined over time. In clinicians have found that certain neuro­ Increasingly sophisticated research addition, screening for any alcohol use behavioral outcomes associated with has improved scientific and clinical under- during pregnancy is difficult. This arti­ prenatal alcohol exposure can persist in standing of the adverse consequences cle discusses the difficulties involved in the affected person into adolescence of prenatal alcohol exposure. The term screening pregnant women for alcohol (Sampson et al. 1994) and adulthood “pregnancy risk drinking” (i.e., drink­ use; details some of the questionnaires, (Kelly et al. 2000). ing during pregnancy at levels consid­ or instruments, available to facilitate Because no universally safe level of ered risky to the fetus) was previously alcohol consumption during pregnancy defined as the consumption of 1 ounce has been identified (Stratton et al. 1996), or more of alcohol (i.e., two or more GRACE CHANG, M.D., M.P.H., is an the U.S. Surgeon General and the drinks) per day (Sokol et al. 1989), but associate professor of psychiatry at Harvard Secretary of Health and Human Services more recent findings show that even Medical School, Department of Psychiatry, recommend abstinence both before con­ lower levels of alcohol consumption can Brigham and Women’s Hospital, Boston, ception and throughout pregnancy lead to negative pregnancy outcomes Massachusetts. (Stratton et al. 1996; Ebrahim et al. 1998). (Charness et al. 1994; Wong et al. 1995; However, approximately 20 percent of Ikonomidou et al. 2000; Jacobson and Preparation of this article was supported women drink some alcohol during preg­ Jacobson 1994). A study of more than in part by National Institute on Alcohol nancy, and the rate of frequent drinking 5,000 pregnant women who consumed Abuse and Alcoholism grants K24–AA– (i.e., seven or more drinks per week or alcohol moderately (defined as at least 00289 and R01–AA–12548. 204 Alcohol Research & Health Screening Instruments for Pregnant Women alcohol screening in this population; and inquiries about drinking patterns before 1996). Progress toward this goal has briefly describes a few laboratory tests pregnancy confirmation are potentially not yet been reported. used for detecting alcohol use among more accurate measures of first-trimester In response to the need for increased pregnant women. drinking (Day et al. 1993). Women are alcohol screening among pregnant women, also likely to deny or minimize their researchers have developed several alcohol- drinking during pregnancy out of embar­ screening instruments specifically for Complications of rassment (Morrow-Tlucak et al. 1989). use with this population. Screening Pregnant Even moderate drinkers may underreport Women for Alcohol Use alcohol consumption during pregnancy (Verkerk 1992). Data from a sample of Screening Instruments A key complication in screening preg­ 361 mothers suggest that women who nant women for alcohol use arises from report drinking more than 1.3 drinks The screening instruments described in the fact that the traditional alcohol- per week during pregnancy actually may this section were tested in diverse clini­ screening questionnaires—such as the be drinking at levels high enough to cal populations and may help identify Michigan Alcoholism Screening Test incur risk for alcohol-related birth defects women using alcohol during pregnancy. (MAST) (Selzer 1971) and the CAGE1 (Jacobson et al. 1991). For example, 53 These instruments vary in that they (Ewing 1984)—are less effective in percent of the women who reported were designed to detect different levels identifying drinking problems among drinking more than 1.3 drinks per week of alcohol use and, therefore, differ in women than among men. This discrep­ during pregnancy reported higher lev­ how they define pregnancy risk drinking. ancy is attributable to the fact that these els of consumption when interviewed In general, a positive screen does not instruments were developed among men, retrospectively. indicate an alcoholism diagnosis; rather, who have different patterns of alcohol A third complication is that standard it may signal to a physician or other consumption and different thresholds questions about quantity and frequency health care practitioner the need to discuss for problem drinking than women of alcohol consumption are unlikely pregnancy risk drinking with a patient. (Babor et al. 1989). In addition, these to be helpful when screening pregnant Routine use of screening questionnaires instruments were developed to detect women for alcohol use. The widely in clinical practices may reduce the alcohol dependence, which is relatively used American College of Obstetricians stigmatization of asking patients about uncommon among pregnant women and Gynecologists (ACOG) Antepartum alcohol use and result in more accurate (Ebrahim et al. 1998). Because of bio­ Record poses three questions about alco­ and consistent evaluation. logical differences between women and hol use: (1) the amount of alcohol con­ Sensitivity and specificity are two men, the same quantity of alcohol con­ sumed per day before pregnancy, (2) the important properties of every screening sumed over the same time period pro­ amount of alcohol consumed per day instrument. The sensitivity of a screen­ duces higher blood alcohol levels in during pregnancy, and (3) the number ing test refers to the probability that a women than in men (Graham et al. of years of alcohol use. The Antepartum person who should test positive, does 1998). Women are also more sensitive Record has a fill-in-the-boxes format so (i.e., the sensitivity of a screen for than men to alcohol-related organ dam- designed to gather standard clinical pregnancy risk drinking is the probabil­ age, such as cardiomyopathy and myopa­ information on obstetric patients. How- ity that a woman who is a risk drinker thy (Urbano-Marquez et al. 1995; ever, compared with the 13-item Prenatal tests positive). The specificity of a Hanna et al. 1992). Therefore, alcohol- Alcohol Use Interview, the ACOG screening test is the probability that a screening-instrument cutoff scores (i.e., Antepartum Record is less successful person who should test negative, does the values that clinicians use to define in identifying prenatal alcohol use. so (i.e., the probability that a woman a positive result from a screening instru­ Researchers suggest that the difference who is not a risk drinker tests negative) ment) most likely need to be set differ­ in findings between the two instruments (Rosner 1990). ently for men and women and particu­ may be attributable to the format of larly for pregnant women (Bradley et the ACOG Antepartum Record and its The T-ACE al. 1998). lack of guiding questions: the ACOG A second complication faced by instrument requires a skilled interviewer The T-ACE was the first validated sen­ researchers is that many women alter their in order to elicit accurate responses about sitive screen for risk drinking (defined alcohol consumption once they learn drinking during pregnancy (Budd et al. as alcohol consumption of 1 ounce or that they are pregnant. Consequently, 2000). more per day) developed for use in A final complication is that obstetri­ obstetric-gynecologic practices (Sokol cians inconsistently screen their patients et al. 1989). An obstetrician developed 1The CAGE screening instrument (Ewing 1984) consists of four questions: (1) Have you ever felt you should Cut for alcohol use during pregnancy.
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