Clinical Approaches to the Assessment of Alcohol Use in Pregnancy
The following was a Telehealth Presentation offered on March 28, 2007 originating in Saskatoon, Saskatchewan.
Speaker: Dr. Peter Selby
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- The three 'A's of brief intervention [ Watch video ]
- Physician concerns in assessing alcohol use in pregnancy [ Watch video ]
- Common drinking patterns [ Watch video ]
- At risk drinking and safe levels in pregnancy [ Watch video ]
- Barriers to assessing alcohol use in pregnancy [ Watch video ]
- The T-ACE assessment tool [ Watch video ]
- When to Ask about alcohol use [ Watch video ]
- How to Advise about alcohol use in pregnancy [ Watch video ]
- Many health care professionals will not say that there is no safe level of alcohol use in pregnancy. How can we avoid giving confusing information to pregnant women?
That is common everywhere, both in Canada and Internationally. It also occurs with smoking in pregnancy; we hear "my doctor told me not to try to quit smoking in pregnancy because it would be too stressful for me". Unfortunately there is no statement in any formal textbook regarding zero tolerance for alcohol use in pregnancy, and it may be that the patient is stating what she wanted the physician to say. This is discussed in what is called the "reasons model". This states that people are faced with challenges to a behavior which is incongruent with health or social acceptability, they have to create reasons to justify that behavior when it is questioned. They may choose to state that they read information in a newspaper article, or in this situation, particularly in an interview with a nurse, that their doctor told them there was no reason to quit; In effect "trumping" the nurse's advice. This is an interesting line of research into the way people defend their behaviors. That is one aspect.
Another aspect is that there are healthcare professionals who continue to give misleading information, so how do we deal with this? The answer is education programs such as this. Healthcare professionals must understand that we are talking about risk. The odds of having harm is greater if the patient drinks alcohol than if they don't so health professionals must consider what kinds of risk they wish their patient's to take. This can be a difficult concept for patients to grasp. In a city environment, when talking to a patient, I use the analogy that there is risk in everyday life so what kind of risk do you take? Are you the kind of person who only crosses the street at a crossing light? That behavior increases your chance of crossing the road safely; however, there is no absolute guarantee. Are you the kind of person who runs in to the middle of the street against the traffic? Eight times out of ten you may make it safely across but two times out of ten you may not. In Northern communities I talk about taking a skidoo out on the ice in the Spring. Most times you may cross the lake safely but there is a much higher risk in this situation that you will not. In education programs like this, information is spread to healthcare professionals in attendance. We hope that these healthcare professionals will spread the information to their peers and therefore healthcare professionals will develop peer guidelines for management of alcohol use in pregnancy.
The other important aspect is that there is no known benefit from taking alcohol in pregnancy, so why take the risk of harm which cannot be reversed?
- How to Assist women to reduce or cease alcohol use in pregnancy [ Watch video ]
- Framework for brief intervention [ Watch video ]
- If a woman in an area with a high incidence of alcohol use states that she does not drink, how far should you press to be sure that this is so?
The stigma of alcohol use can indeed act against disclosure so it's important to create a context for disclosure during screening. Try to make the screening setting comfortable and a safe place for discussion of drinking and the patient's difficulties with alcohol so that this can be discussed in a non-judgmental setting.
Asking the question "how much do you drink" rather than "do you drink" is a good way to start. You can also ask, "when was the last time you drank beer, wine, spirits, etc.?" Also indicate that you ask all women in this situation about their alcohol consumption in the last thirty days. Always keep in mind that there may be some intergenerational risk, that is the patient themselves may have been alcohol exposed by their own mothers or may be drinking to mask depression. If available in your community anonymous testing of meconium may give a true prevalence of substance usage in any given population.
- How do you counsel a woman who has taken alcohol before she realizes that she is pregnant?
We talk about the spontaneous rate of miscarriage in the first trimester primarily due to poor development. We say that one in four women who get pregnant will miscarry just because the sperm and egg do not get together correctly and this is the body's natural way of dealing with this. So, whether or not you drink, this can happen. Because one of the things that happens to a woman who has taken alcohol before she realizes she is pregnant is that she will connect any adverse outcome to that alcohol use whether or not it is a correct attribution. Also, three to five percent of pregnancies will have a birth defect and we can't always relate this to drinking at critical times in any pregnancy, but if you avoid alcohol for the rest of the pregnancy you can avoid many of the brain development defects, which can occur at any stage in the pregnancy. The chances (not the absolute underlying effect) are that your child will not be further affected. The other route for support is to refer the patient to Mother Risk by telephone.
Of course in this situation the worst case scenario is that the patient elects for a termination based on fear and not on evidence.
- How can health professionals work in the community to create support for women who wish to stop drinking during their pregnancies?
The origins of my work with this was with the Ontario "Best Start" program. We had a project in which we developed materials then asked communities to identify key opinion leaders in health professions and brought them in to a Train the Trainer workshop, with the proviso that they would return to their communities to help other health professionals be supportive and to establish capacity for patient support.
At last count the 20 original health professionals have trained 500 others using Grand Rounds and community education as tools.
In Ontario, and maybe in Saskatchewan, health professionals and professional agencies are often isolated from community agencies who share the same goals so we need to build bridges between us.
Please click here to see the PowerPoint presentation of the Clinical Approaches to the Assessment of Alcohol Use in Pregnancy.
Please click here to see the Alcohol Risk Assessment Professional's Manual.
Please click here to see the Alcohol T-ACE Screening Tool Card.
Please click here to see the Alcohol Risk Assessment Brochure.