Pregnant women are particularly receptive to health promotion and education, as evidenced by the increased rates of breastfeeding (Centers for Disease Control and Prevention, 2016), the increased rates of safe infant sleep patterns (Colson et al., 2009), and the decreased rates of tobacco use during pregnancy (Curtin & Matthews, 2016). Although these positive trends are reported, women who are pregnant, or women of childbearing age who are casually using contraceptives, may consume alcohol, a known teratogen. Prenatal alcohol exposure can lead to a spectrum of 100% preventable disorders, commonly referred to as fetal alcohol spectrum disorder (FASD).
FASD is composed of several diagnoses across a continuum including fetal alcohol syndrome (FAS), partial FAS (pFAS), alcohol-related neurodevelopmental disorders, and many others. FAS has clear and well-defined diagnostic criteria: cardinal facial dysmorphias, growth below the 10th percentile, and evidence of central nervous system damage. Many affected individuals do not meet diagnostic criteria for FAS, yet still fall along the FASD continuum. The implications for those affected can be devastating, especially if the typical "red flags" (such as physical abnormalities) are not present and the individual is not able to receive early treatment and interventions. The range of effects that an individual with FASD may experience is lifelong and often presents as a "hidden" disability. In addition, those with FASD are at an increased risk for a variety of comorbidities, including attention deficit hyperactivity disorder, communication disorders, psychiatric disorders, and sensory processing issues. These conditions can interfere with the ability of affected individuals to lead a physically, mentally, and spiritually healthy life.
Although most individuals consume alcohol at safe and low-risk levels (National Institute on Alcohol Abuse and Alcoholism, 2016), many individuals, including nurses and other healthcare providers, are unaware of the risks of moderate- and high-risk alcohol use. Alcohol use in the United States is a socially and culturally accepted means for celebration and self-medication. Furthermore, alcohol consumption continues to be normalized through advertising and social media.
According to the National Institute on Alcohol Abuse and Alcoholism (2016), women are recommended to drink no more than three drinks on a single day and no more than seven drinks in a week. Among nonpregnant women of childbearing age (18-44 years), over 50% have reported alcohol use in the past 30 days, whereas nearly 20% reported binge drinking (consuming four or more drinks in a 2-hour period; Tan, Denny, Cheal, Sniezek, & Kanny, 2015). Approximately 10% of pregnant women have reported alcohol use within the past 30 days, whereas 3% reported binge drinking (Tan et al., 2015). The highest reported prevalence of alcohol consumption during pregnancy included women who were 35-44 years old, college educated, employed, and unmarried (Tan et al., 2015). These statistics highlight that women who are pregnant and/or trying to become pregnant may not be receiving adequate education about the risks of prenatal alcohol consumption, the leading preventable cause of birth defects and disabilities (such as FASD) in the United States (Centers for Disease Control and Prevention, 2014). Although the prevalence of FASD is difficult to delineate because it is often underdiagnosed or misdiagnosed, it is estimated that up to 5% of individuals in the United States may be affected (May et al., 2014).
In a study, Finer and Zolna (2016) report that up to 45% of all pregnancies in the United States are unplanned. Therefore, women may be consuming alcohol before they are aware of their pregnancy. There is no period of pregnancy in which alcohol consumption is known to be safe. Most of the structural damage, such as the facial dysmorphias associated with FAS, occurs during the first half of pregnancy. Yet, alcohol consumption during the last trimester can be associated with central nervous system dysregulation, such as damage to the cerebellum, and subsequently, lifelong balance, coordination, and/or memory impairments.
The U.S. Surgeon General has supported these findings, making the statement, "no amount of alcohol consumption can be considered safe during pregnancy" (Office of the Surgeon General, 2005). FASD is 100% preventable, and despite the aforementioned facts, we continue to see new cases each year. This may be because many women, nurses, and other healthcare providers remain unaware that alcohol is the most dangerous substance for prenatal consumption, even more so than illicit substances such as heroin or cocaine.
Undoubtedly, both nurses and other healthcare providers who frequently encounter women of childbearing age must integrate prevention techniques into their standard of care and routine practice. Such techniques may include education and screening. It is recommended that screening for alcohol use be done on at least an annual basis with a validated tool, such as the AUDIT. If the screen is negative, meaning the individual is consuming alcohol at low-risk levels, an opportunity is available for positive reinforcement for continuing healthy behaviors. If the result of the screen is positive, a teachable moment exists, and an opportunity for a brief intervention, using motivational interviewing techniques, is readily available. At this time, the healthcare provider has an opportunity to educate and encourage low-risk alcohol consumption. Referral to treatment should be implemented for those who are identified as consuming alcohol at high-risk levels. Screenings and brief interventions can be conducted quite efficiently in any clinical setting, yielding effective results.
Any alcohol use in pregnant women, women who are trying to become pregnant, or women of childbearing age who are not using effective contraception is considered "high risk" regardless of the reported amount of alcohol consumed. High-risk individuals should be provided with education regarding FASD as a result of prenatal alcohol exposure. It is imperative to provide women with the tools and resources to make healthy and informed decisions regarding their pregnancy.
Because nurses are the most trusted healthcare professionals, they are in an ideal position to ensure that all women are provided with the evidence-based information necessary to make healthy decisions regarding alcohol use before, during, and after the prenatal period. Nursing faculty, students, and practicing nurses must be provided with up-to-date information to have a positive impact on women's health. It is essential that programs addressing FASD and screening, brief intervention, and referral to treatment be made available in nursing curricula and ongoing continuing education programs throughout the country, so that nursing professionals are well equipped to work with women of childbearing age.
Acknowledgment
This project was supported in part by funds from the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, under Grant number 1U84DD001135.
REFERENCES