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Project Overview

Aristotle wrote of the harm done to the unborn child by alcohol use in pregnancy. Wood etchings from the 1700’s depicting the scourge of the gin epidemic in England portray children with facial features characteristic of Fetal Alcohol Syndrome (FAS). In the mid-1940’s, the Journal of the American Medical Association described the “defects” found in children born to alcoholic women, but attributed the children’s difficulties to the “defective stock of the parents.”¹

Despite this early recognition of the significant health and mental health problems alcohol consumption during pregnancy can cause, slow progress is being made in integrating routine screening for alcohol use into primary care for pregnant women and women of child-bearing age. In fact, physicians rarely ask a pregnant woman about her alcohol use, and FAS remains the most common cause of diagnosable mental retardation in the United States as well as one of the leading causes of behavioral problems in children.² The United States government and its public agencies have recognized the severity of these problems and, in Healthy People 2010, has set a goal (# 16-17) of 94% abstinence from alcohol and 100% abstinence from binge drinking in the past month among pregnant women.³

But we are far from reaching that goal. For in spite of professed public and professional concern over the consequences of prenatal alcohol exposure, the American College of Obstetricians and Gynecologists documented the low priority that obstetricians place on advising their patients about alcohol use during pregnancy.⁴ Although 97% of obstetricians declared that they asked their patients about alcohol use, 80% confirmed that they advise their patients that “a little alcohol” does not pose a threat to the pregnancy or the developing fetus. In addition, 4% of the obstetricians surveyed stated that 8 drinks or more per week was a “safe” level of alcohol consumption for pregnant women. This of course is in direct contrast to a recent study which documented that any alcohol use in pregnancy places the child at more than three times increased risk for delinquent behavior.⁵

Although the lack of an appreciation for alcohol’s toxicity stands at the heart of the problem, legal, social, and attitudinal barriers often come together to restrain open communication between prenatal care provider and patient. Most pregnant women state that they simply will not talk to primary care providers about their alcohol use, the most common reason given being the fear of prosecution or loss of their baby to the child protection system.⁶

There is good reason for this fear. When screening for alcohol use is implemented in clinical practice, it often focuses on targeted populations rather than the general population entering prenatal care. Providers often state that they can “tell” who is an alcoholic by looking at the person. A 1990 study of substance use in pregnancy in Pinellas County, Florida,⁷ revealed that although the overall use of alcohol and illicit substances was approximately 15% in both African American women and in White women within the population, African American women were ten times more likely to have a urine toxicology performed or to have intensive evaluation for substance use than were white women. This study demonstrated that physicians’ selection of pregnant women for substance use evaluation was based on two factors: race and social class.

On a more positive note, much recent work has focused on universal screening of pregnant women for risk of alcohol use. A recent ACOG publication⁸ emphasizes the importance of addressing risk for substance abuse, domestic violence, and mental health problems within the context of primary prenatal care, and a recent study of doctors’ willingness to intervene in patients’ drug and alcohol problems revealed overall positive attitudes toward the physician’s role in screening and working with families affected by alcohol or other drug use.⁹

However, screening cannot stand alone; it is essential that screening take place in the context of a much larger integrated system of screening, assessment, referral, and treatment. If there is no capability to educate the pregnant woman about the dangers of alcohol use, if there is no ability to provide direct interventions, or if there is no treatment available for the woman or her affected child, efforts to identify the at-risk woman can result in punitive policies that disrupt families and drive pregnant women out of prenatal care, further complicating medical risk for the pregnancy and the baby.

This is where we stand today. Universal prevention and early intervention efforts regarding alcohol use in pregnancy continue to be considered a peripheral issue to health care in the opinion of many health care providers. Integrated systems that link the woman in prenatal care to educational and treatment resources remain elusive. The organizations that have joined together for this project are dedicated to integrating the prevention, identification, and support of individuals with Fetal Alcohol Syndrome into primary health care across the nation:

• Children's Research Triangle
• Title V Agencies of Illinois, California, New Jersey, Oregon, Nevada, and Hawaii
  
• American Medical Association
• March of Dimes
• MCAH Action of California
• American Academy of Pediatrics/New Jersey Chapter Pediatric Council on Research & Education
• Illinois State Medical Society
• Prevention First Illinois

Purpose
The purpose of this project is to develop a training and technical assistance program for Community Health Centers and maternal and child health sites that will impact clinical practice in three arenas:

• Prevention
  Train all clinic personnel to communicate the message that there is no safe amount of alcohol to drink during pregnancy and to use prevention and education materials that promote healthy pregnancies free of alcohol use.
• Identification
  Train all prenatal care providers to screen pregnant women for alcohol use and all children’s health providers to screen children for evidence of FASD.
• Support individuals with FASD
  Train all providers in strategies for ensuring access to early and appropriate intervention for all pregnant women found to be using alcohol and all children who have been affected by prenatal alcohol exposure.

The project will include a full curriculum with print, electronic, and video support materials that can be utilized to replicate the training program in communities and clinical programs across the nation.

From 2000 through 2005, Children's Research Triangle was funded by the Maternal and Child Health Bureau (MCHB) to develop strategies for integrating alcohol screening into primary prenatal care sites. These studies were conducted in MCHB Healthy Start programs in Illinois, all of whom provided prenatal care to women enrolled in Community Health Centers. In addition, CRT was funded by MCHB to provide training and technical assistance to Healthy Start sites across the nation to promote screening of pregnant women for alcohol, tobacco, and illicit drug use within the prenatal care setting. Based on our work with the Healthy Start sites and their affiliated Community Health Centers, we have selected three new states in which to implement this project in the year 2008: Hawaii, Nevada, and Oregon.

Why is it so difficult to institute change in a community health care system when the need for change is clear? When the health and well-being of women and their children are involved, one would expect a sense of urgency and no shortage of people willing to do whatever is necessary. In fact, each community has some people and a few institutions who are devoted to helping pregnant and parenting women who are using alcohol, but the efforts of a few are never enough to create systems change.

• A community-based approach places a special emphasis on the breadth of the effort.
• It is not narrowly medical, though it depends heavily on the community’s physicians.
• It is not a public health initiative alone, though the role of public health nurses and outreach workers is essential.
• It is not driven by drug treatment in the sense that the whole effort occurs in the treatment center, though all is for naught if quality treatment is not provided.
• The business community, the church community, and the schools all have a stake in the success of the effort and can play an important role.

The list goes on. The point is that the authority of the approach comes from the broad base upon which it rests and in which it is rooted. Clearly, a simplistic training approach with direct service providers will not work to change behavior within health care systems. A model of a community-based training and intervention that resembles our proposed approach was described in an article appearing in the Journal of the American Medical Association.42 The results of the study showed that a coordinated, comprehensive community-based intervention can reduce high-risk alcohol consumption and injuries resulting from alcohol-related motor vehicle accidents. For example, with a heavy emphasis on training across the spectrum of primary contact, bartenders were given beverage service training to coincide with enhanced law enforcement and a mobilization of the media to draw attention to the problem of drinking and driving. In our approach, we will train all individuals working in the CHC or maternal and child health site to communicate a consistent message of abstinence from alcohol prior to and throughout pregnancy.

1. Journal American Medical Association, 132:419, 1946
2. Streissguth AP, Sampson P, Barr H. Neurobehavioral dose-response effects of prenatal alcohol exposure in humans from infancy to adulthood. Annals of the New York Academy of Science 1989;562: 145-158.
3. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. Washington, DC: U.S. Government Printing Office, November 2000.
4. American College of Obstetrics and Gynecology. Technical Bulletin, 2000.
5. Sood B, Delaney-Black V, Covington C, et al. Prenatal alcohol exposure and childhood behavior at age 6 to 7 years: I. Dose-response effect. Pediatrics 2001;e34,1-9.
6. Maliza B. Most pregnant women don’t disclose drug use. Society for Maternal-Fetal Medicine, New Orleans, LA, 2002.
7. Chasnoff IJ, Landress HJ and Barrett ME. The prevalence of drug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida. N Engl J Med 1990; 202-1206.
8. Psyochosocial Issues in Pregnancy. American College of Obstetrics and Gynecology. Washington DC, 2002.
9. Roche AM and Richard GP. Doctors' willingness to intervene in patients' drug and alcohol problems. Soc Sci Med , 33:1053-1061, 1991.