Drinking During Pregnancy

Introduction

This toolkit summarizes content from the Drinking During Pregnancy Evidence Accelerator and the MCHbest database. The peer-reviewed literature supporting this work can be found in the Established Evidence database. Use the resources below as you develop effective evidence-based/informed programs and measures.

From the MCH Block Grant Guidance. Fetal alcohol spectrum disorders (FASDs), which result in life-long physical and cognitive and/or behavioral problems, are caused by drinking during pregnancy.¹ Fetal alcohol syndrome (FAS) represents the severe end of FASDs, and is characterized by abnormal facial features (e.g., smooth ridge between nose and upper lip), lower than average height or weight, and central nervous system problems that create deficits in learning, memory, attention, communication, vision, and/or hearing.¹ While there is no known safe level of alcohol consumption in pregnancy, binge drinking and regular heavy drinking pose the greatest risks to fetal development.² In 2018-2020, 13.5% of pregnant adults reported drinking any alcohol in the past 30 days, and 5.2% reported binge drinking.³

Goal. To reduce the percent of infants born with fetal alcohol spectrum disorders.

Note. Access other related measures in this Population Domain through the Toolkits page.

Overview: Read a summary of the issue related to Title V

Prenatal alcohol exposure is a leading preventable cause of birth defects and developmental disabilities.¹ Multiple federal and non-federal health agencies recommend that pregnant women and those planning to become pregnant abstain from alcohol. Any alcohol use is considered unhealthy during pregnancy.¹ Although most women stop drinking alcohol when they realize they are pregnant, there are women who continue to drink at levels that are hazardous to the fetus, who may be suffering from alcohol use disorders.² Binge drinking alcohol during pregnancy is defined as having four or more alcoholic drinks on at least one occasion in the past 30 days.³ All types of alcohol are equally harmful, including wine and beer.⁴ Alcohol crosses the placenta with fetal blood alcohol levels approaching maternal levels within two hours of maternal intake.⁵

Prenatal alcohol exposure can result in a range of adverse outcomes, including preterm birth, low birth weight, and Fetal Alcohol Syndrome (FAS).¹ Fetal Alcohol Spectrum Disorders (FASDs) are defined as a group of conditions that can occur in a person who was exposed to alcohol before birth.⁶ The term describes the range of lifelong physical, mental, and behavioral effects that can occur in an individual exposed to alcohol in utero.⁷ Often, a person with FASD has a mix of physical, behavior, and learning problems, and conditions can range from mild to severe.⁶ Impairments may appear at any time during childhood and last a lifetime.⁷

Research has found that pregnant women may underreport drinking, may not recognize how much they drink, or how harmful alcohol can be at non-dependent drinking levels.⁸ Women are generally accepting of alcohol use screening, so prenatal care visits provide an opportunity for intervention.⁸ The American College of Obstetricians and Gynecologists endorsed use of routine screening, brief intervention, and referral to treatment for alcohol and other substances as part of comprehensive obstetric care starting at the first prenatal visit.⁹ A brief alcohol-screening questionnaire that was specifically developed for the prenatal setting and with the highest at-risk drinking sensitivity is the T-ACE.^{10, 11} Although screeners suffer from an underreporting bias due to inaccurate patient recall, embarrassment, or denial regarding actual consumption, clear and consistent advice, given in a compassionate manner, can support behavior change.⁸

Detail Sheet: Start with the MCH Block Grant Guidance

DEFINITION

Numerators:

A) Number of women who reported having any alcoholic drinks during any trimester of pregnancy

B) Number of women who reported having 4 or more alcoholic drinks in a 2-hour timespan during any trimester of pregnancy

Denominator:

Number of women with a recent live birth

Units: 100

Text: Percent

HEALTHY PEOPLE 2030 OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) 09: Increase abstinence from alcohol among pregnant women. (Baseline: 89.3% of pregnant females aged 15 to 44 years reported abstaining from alcohol in the past 30 days in 2017-18, Target: 92.2%)

DATA SOURCES

Pregnancy Risk Assessment Monitoring System (PRAMS)

MCH POPULATION DOMAIN

Perinatal/Infant Health

MEASURE DOMAIN

Health Behavior

Data Sources: Learn more about the issue and access the data directly

This SM is measured through data collected from the Pregnancy Risk Assessment Monitoring System (PRAMS). Other data sources, such as the Behavioral Risk Factor Surveillance System (BRFSS), also collects data on alcohol during pregnancy. During 2018-2020, 13.5% of pregnant women reported current drinking and 5.2% reported binge drinking according to CDC estimates from BRFSS data.³ Both estimates were 2% higher than during 2015-2017.³

1. Accelerate with Evidence—Start with the Science

The first step to accelerate effective, evidence-based/informed programs is ensuring that the strategies we implement are meaningful and have high potential to affect desired change. Read more about using evidence-based/informed programs and then use this section to find strategies that you can adopt or adapt for your needs.

Evidence-based/Informed Strategies: MCHbest Database

The following strategies have emerged from studies in the scientific literature as being effective in advancing the measure. Use the links below to read more about each strategy or access the MCHbest database to find additional strategies.

Chart of Evidence-Linked Strategies and Tools
Evidence-Informed			Evidence-Based
Mixed Evidence	Emerging Evidence	Expert Opinion	Moderate Evidence	Scientifically Rigorous
Policy and Legislation (2020)	Medicaid Expansion (2020)		Education and Awareness Campaigns (2018) Integrated Behavioral Interventions (2017) Media Campaigns (2020) Motivational Interviewing (2018) Preconception Education Interventions (2021) Screening and Brief Interventions (2020)	Nurse-Family Partnership (NFP) (2020)

Field-Based Strategies: Find promising programs from AMCHP’s Innovation Hub

Cutting Edge:

12-Month Perinatal Wellness Training Program (OK; 2022)

Emerging:

Fetal Alcohol Syndrome Program (MN; 2008)
Medical Provider Training on FASD (MN; 2008)
Promoting Healthy Prenatal and Parenting Behavior (MN; 2011)
Women of Childbearing Age Peer to Peer Support Groups (NJ; 2021)

Promising:

Comprehensive Pregnancy Health Education for Teens (AZ; 2019)
Health Education, Case Management, and Patient Navigation (NY; 2019)
Perinatal Substance Use Identification and Intervention (IN; 2018)

Best:

Case Management Model for Pregnant and Parenting Mothers (WA; 2012)
Parenting Teamwork Training (CA; 2022)

Key Findings and Emerging Issues: Read more from the literature

Key Findings

There is no known safe amount of alcohol use during pregnancy or while trying to get pregnant. There is also no safe time for alcohol use during pregnancy. All types of alcohol are equally harmful, including all wines and beer.²⁰
The literature does not differentiate approaches between strategies to prevent women who drink any alcohol or who binge drink during pregnancy.
Honest maternal disclosure of alcohol intake is necessary to increase the efficacy of intervention programs to reduce alcohol-exposed pregnancies.²¹
Increased reporting of alcohol use can be attributed to increased knowledge of the risks of prenatal alcohol exposure and improved screening and recording of alcohol use as part of a community-led FASD prevention strategy.²²
Studies indicate that participants in brief intervention groups show significant reductions in the rate of unprotected sex, risky drinking, and alcohol-exposed pregnancy risk from pre-treatment to post-treatment and to the 6-month follow-up.²³

Research. Multiple strategies are emerging as potential approaches to advance this SM but haven’t been studied with enough rigor to be included in the evidence-based continuum. Additional research is needed to verify outcomes, but initial studies have shown promise:

Using social media to promote awareness and recruitment of participants into intervention programs to prevent or reduce alcohol-exposed pregnancies.²⁴
Building trust and creditability for recruitment purposes in interventions by conducting in-person outreach within communities that allows direct connections with women.²⁵
Tailoring web-based interventions designed for audiences at risk with the goal of promoting healthy behaviors and reducing alcohol-exposed pregnancies.²⁶
Identifying precursors for risky drinking patterns during the prenatal/postpartum periods and addressing factors such as access to alcohol and pregnancy-related changes for young mothers.²⁷

Research Gaps: Learn where more study is needed

Topical Area Knowledge Gaps. Lack of studies on:

Identifying additional risk and protective factors that contribute to alcohol use during pregnancy.
Investigating barriers that pregnant women face in accessing care and support for alcohol use during pregnancy.
Conducting research on the integration of alcohol screening and intervention into preconception care.
Exploring cultural and ethnic variations in drinking behaviors during pregnancy.

Specific Intervention Research Gaps. Lack of studies on:

Examining the effectiveness of training programs for healthcare providers in addressing alcohol use during pregnancy.
Using social media to promote awareness and recruitment of participants into intervention programs to prevent or reduce alcohol-exposed pregnancies.
Building trust and creditability by conducting in- person outreach within communities that allows direct connections with women.
Tailoring web-based interventions with the goal of reducing alcohol- exposed pregnancies.

Methodological Gaps. Lack of studies on:

Evaluating the effectiveness of interventions aimed at reducing alcohol consumption during pregnancy.

Strategy Video: Watch a summary of evidence-based/informed strategies

Watch a short video discussing state-of-the-art, evidence-based/informed strategies that can be used or adapted as ESMs. Experts in the field discuss approaches, the science, and specific ways that Title V agencies can implement and measure these approaches. Presented by EXAMPLE_video_presenters

2. Think Upstream with Planning Tools—Lead with the Need

The second step in developing effective, evidence-based/informed programs challenges us to plan upstream to ensure that our work addresses issues early and is measurable in “turning the curve” on big issues that face MCH populations. Read more about moving from root causes to responsive programs and then use this section to align your work with the data and needs of your populations.

A. Move from Need to Strategy

Use Root-Cause Analysis (RCA) and Results-Based Accountability (RBA) tools to build upon the science to determine how to address needs.

Planning Tools: Use these tools to move from data to action

B. Align with the Needs of the Population

Consider the following findings related to this performance measure.

The Role of Title V: Get ideas on how to implement strategies

Title V agencies can collaborate with other agencies, health care providers, and community organizations to address drinking during pregnancy by:

Disseminating educational materials and supporting community outreach programs to increase awareness about risks of alcohol use.¹⁷
Offering provider trainings to increase knowledge of promising and effective practices, such as electronic alcohol screenings.¹⁸
Supporting emerging technology-based interventions, such as text messages in mobile health programs, to reduce prenatal alcohol use.¹

SDOH and Health Equity Considerations: Identify ways to advance health for all

Social Determinants of Health (SDOH)

Alcohol use during pregnancy is intertwined with structural and SDOH, such as early childhood experiences of trauma and violence, mental health challenges, racism and discrimination, as well as lack of access to services and supports for mental health and trauma.¹² Pregnant women with frequent mental distress were 2.3 to 3.4 times as likely to report current and binge drinking, respectively, compared with those without frequent distress.³ Pregnant women without a usual health care provider were also 1.7 times more likely to report current drinking than those with a current provider.³

Strategies to address structural and SDOH include:

Utilizing trauma-informed approaches to help address the root causes of alcohol use during pregnancy, as well as the stigma around women’s use of alcohol during pregnancy.¹²
Integrating mental health care into clinical care and increasing access to care to help address alcohol use and mental distress during pregnancy.³
Having a regular health care provider or usual source of prenatal care who screens for alcohol use and acts as an entry point for specialized services for alcohol use challenges.¹²
Promoting protective factors during the prenatal period for pregnant women, such as social support and peer connections, to foster a sense of belonging, community, safety, and hope.¹²

Health Equity

According to data from the National Survey on Drug Use and Health for years 2002-2017, among all pregnant women, factors associated with higher risk of any use or binge drinking were early pregnancy, other substance use, alcohol use disorders, depression, and being unmarried.¹³ For any drinking, higher risk was associated with higher socioeconomic status and adolescence.¹³ For binge drinking, in early pregnancy, lower risk was associated with ages 35-44, while in middle/later pregnancy, higher risk was associated with lower socioeconomic status and Black race/ethnicity.¹³ Of women who drink in pregnancy, there is an increased risk of FAS in those who are of older maternal age, high parity, and African American or Native American ethnicities.⁵

For Indigenous women, influences such as isolation, cultural barriers, and historical trauma have made it uniquely challenging to prevent alcohol use during pregnancy.¹⁴ Findings from the Safe Passages study of a rural Tribal Nation in the central U.S. revealed factors that were protective against substance use during pregnancy: living with someone, having 12 years or more of education, being employed, and not being depressed.¹⁴ Culturally appropriate screening and programs are needed to eliminate inequities in poor outcomes associated with prenatal drinking.¹⁴

Special Considerations: Tease out ways to zoom in on populations of focus

If a woman has a child with FASD, she often experiences many forms of judgment, assumptions, guilt, fear, and shame, and these experiences are a significant barrier to accessing support and care.¹³ With much greater emphasis and concern for children with FASD and not the mothers themselves who are struggling, this can lead to children being removed from their mother’s care and placed in foster care with no clear mandate to support the mother. The most promising practices to reduce drinking during pregnancy involve using a collaborative and relational approach to provide integrated and comprehensive supports enabling women to feel welcomed, free of judgment, seen, and treated as a whole person.¹³ Providing such supports necessitates trauma-informed training, education, and policies for the people responsible for programs, supports, and services for pregnant and parenting women who drink alcohol.¹³

3. Work Together with Implementation Tools—Move from Planning to Practice

The third step in developing effective, evidence-based/informed programs calls us to work together to ensure that programs are movable within the realities of Title V programs and lead to health equity for all people. Read more about implementation tools designed for MCH population change and then use this section to develop responsive strategies to bring about change that is responsive to the needs of your populations.

Additional MCH Evidence Center Resources: Access supplemental materials from the literature

Find field-based resources focused on decreasing drinking during pregnancy relevant to Title V programs in the MCH Digital Library.
Search the Established Evidence database for peer-reviewed research articles related to strategies for decreasing drinking during pregnancy.
Request Technical Assistance from the MCH Evidence Center
MCH Evidence Center Frameworks and Toolkits:

Implementation Resources: Use these field-generated resources to affect change

Practice. The following tools can be used to translate evidence to action to advance this SM:

Screening, Brief Intervention, & Referral to Treatment (SBIRT) (New York State). This tool assesses the severity of substance abuse and identifies appropriate levels of treatment.
Alcohol Screening and Brief Intervention: A Guide for Public Health Practitioners (APHA). The guide provides information, skills, and tools needed to conduct alcohol-related Screening and Brief Interventions (SBIs).

Partnership. The following organizations have developed tools to address drinking during pregnancy:

Substance Abuse and Mental Health Services Administration (SAMHSA). Offers a National Helpline and Treatment Referral.
American Addiction Centers. Maintains an Alcohol and Pregnancy Portal with information and sources of assistance for women and families.

References

Introductory References: From the MCH Block Grant Guidance

¹ Centers for Disease Control and Prevention. Fetal Alcohol Spectrum Disorder (FASDs). 2022 November 4. https://www.cdc.gov/ncbddd/fasd/facts.html
² National Institute on Alcohol Abuse and Alcoholism. Fetal Alcohol Exposure. 2021 June. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/fetal-alcohol-exposure
³ Gosdin LK, Deputy NP, Kim SY, Dang EP, Denny CH. Alcohol Consumption and Binge Drinking During Pregnancy Among Adults Aged 18-49 Years - United States, 2018-2020 [published correction appears in MMWR Morb Mortal Wkly Rep. 2022 Jan 28;71(4):156]. MMWR Morb Mortal Wkly Rep. 2022;71(1):10-13. Published 2022 Jan 7. doi:10.15585/mmwr.mm7101a2 https://www.cdc.gov/mmwr/volumes/71/wr/mm7101a2.htm

Toolkit References: From the Evidence Accelerator

1. Floyd, RL, Ebrahim, S, Tsai, J, O’Connor, M, Sokol, R. (2006). Strategies to reduce alcohol-exposed pregnancies. Maternal and child health journal, 10, 149-151.

2. DeVido, J, Bogunovic, O, Weiss, RD. (2015). Alcohol use disorders in pregnancy. Harvard review of psychiatry, 23(2), 112–121.

3. Gosdin LK, Deputy NP, Kim SY, Dang EP, Denny CH. Alcohol Consumption and Binge Drinking During Pregnancy Among Adults Aged 18–49 Years — United States, 2018–2020. MMWR Morb Mortal Wkly Rep 2022;71:10–13.

4. Centers for Disease Control and Prevention. (2024 May). About Alcohol Use During Pregnancy | Alcohol and Pregnancy | CDC.

5. Dejong, K., Olyaei, A., & Lo, J. O. (2019). Alcohol Use in Pregnancy. Clinical obstetrics and gynecology, 62(1), 142–155.

6. CDC. (2023 October). Fetal Alcohol Spectrum Disorders (FASDs) | CDC

7. National Institute on Alcohol Abuse and Alcoholism. (2023 August). Understanding Fetal Alcohol Spectrum Disorders.

8. Ujhelyi Gomez, K., Goodwin, L., Chisholm, A., & Rose, A. K. (2022). Alcohol use during pregnancy and motherhood: Attitudes and experiences of pregnant women, mothers, and healthcare professionals. PloS one, 17(12), e0275609.

9. Association of Maternal & Child Health Programs. (October 2020). Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Pregnant and Postpartum Women. Opportunities for State MCH Programs.

10. Retrieved from: https://projectteachny.org/app/uploads/2022/07/T-ACE_alcohol_screen.pdf

11. Chang, G., Fisher, N. D., Hornstein, M. D., Jones, J. A., & Orav, E. J. (2010). Identification of risk drinking women: T-ACE screening tool or the medical record. Journal of women's health (2002), 19(10), 1933–1939.

12. Morton Ninomiya, M. E., Almomani, Y., Dunbar Winsor, K., Burns, N., Harding, K. D., Ropson, M., Chaves, D., & Wolfson, L. (2023). Supporting pregnant and parenting women who use alcohol during pregnancy: A scoping review of trauma-informed approaches. Women's health (London, England), 19, 17455057221148304.

13. Shmulewitz, D., & Hasin, D. S. (2019). Risk factors for alcohol use among pregnant women, ages 15-44, in the United States, 2002 to 2017. Preventive medicine, 124, 75–83.

14. Jorda, M., Conant, B. J., Sandstrom, A., Klug, M. G., Angal, J., & Burd, L. (2021). Protective factors against tobacco and alcohol use among pregnant women from a tribal nation in the Central United States. Plos one, 16(2), e0243924.

15. American Public Health Association. (2019 November). Addressing alcohol-related harms: A population level response.

16. Tan, C. H., Denny, C. H., Cheal, N. E., Sniezek, J. E., & Kanny, D. (2015). Alcohol use and binge drinking among women of childbearing age—United States, 2011–2013. Morbidity and Mortality Weekly Report, 64(37), 1042-1046.

17. CDC. (2024 May). Resources for Healthcare Professionals and Patients Toolkit | Alcohol and Pregnancy | CDC.

18. CDC. Alcohol use, screening, and brief intervention among pregant persons – 24 U.S. jurisdictions, 2017 amd 2019. MMWR Morb Mortal Wkly Rep 2023;72(3):55–62.

19. Chang, G. (2023). Reducing Prenatal Alcohol Exposure and the Incidence of FASD: Is the Past Prologue? Alcohol Research: Current Reviews, 43(1).

20. Centers for Disease Control and Prevention. Alcohol Use During Pregnancy. October 2, 2023

21. Morrello, R., Cook, P. A., & Coffey, M. (2022). "Now, with a bit more knowledge, I understand why I'm asking those questions." midwives' perspectives on their role in the Greater Manchester health and social care partnership's programme to reduce alcohol exposed pregnancies. Midwifery, 110, 103335.

22. Symons, M., Carter, M., Oscar, J., Pearson, G., Bruce, K., Newett, K., & Fitzpatrick, J. P. (2020). A reduction in reported alcohol use in pregnancy in Australian Aboriginal communities: a prevention campaign showing promise. Australian and New Zealand journal of public health, 44(4), 284–290.

23. Ingersoll, K., Frederick, C., et al. (2018). A Pilot RCT of an Internet Intervention to Reduce the Risk of Alcohol-Exposed Pregnancy. Alcoholism, clinical and experimental research, 42(6), 1132–1144.

24. Kaufman, C. E., Asdigian, N. L., et al. (2023). A virtual randomized controlled trial of an alcohol-exposed pregnancy prevention mobile app with urban American Indian and Alaska Native young women: Native WYSE CHOICES rationale, design, and methods. Contemporary clinical trials, 128, 107167.

25. Hanson, J. D., Oziel, K., Sarche, M., MacLehose, R. F., Rosenman, R., & Buchwald, D. (2021). A culturally tailored intervention to reduce risk of alcohol-exposed pregnancies in American Indian communities: Rationale, design, and methods. Contemporary clinical trials, 104, 106351.

26. Hanson, J. D., Weber, T. L., et al. (2020). Acceptability of an eHealth Intervention to Prevent Alcohol-Exposed Pregnancy Among American Indian/Alaska Native Teens. Alcoholism, clinical and experimental research, 44(1), 196–202.

27. Tung, I., Chung, T., Krafty, R. T., Keenan, K., & Hipwell, A. E. (2020). Alcohol Use Trajectories Before and After Pregnancy Among Adolescent and Young Adult Mothers. Alcoholism, clinical and experimental research, 44(8), 1675–1685.

Evidence Tools Drinking During Pregnancy