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Alcohol Use and Binge Drinking Among Women of Childbearing Age: USA 2011–13

Cheryl H. Tan, MPH; Clark H. Denny, PhD; Nancy E. Cheal, PhD; Joseph E. Sniezek, MD; Dafna Kanny, PhD

SummaryFull ArticleReferences

Introduction-Excessive alcohol use is a risk factor for a wide range of health and social problems including liver cirrhosis, certain cancers, depression, motor vehicle crashes, and violence. Alcohol consumption during pregnancy is also a risk factor for fetal alcohol spectrum disorders (FASDs) and other adverse birth outcomes, making alcohol use during pregnancy a leading preventable cause of birth defects and developmental disabilities. There is no known safe amount of alcohol consumption during pregnancy.

Discussion-In 2011–2013, 1 in 10 pregnant women reported consuming alcohol in a 30-day period and 1 in 33 reported binge drinking; similar to non-pregnant women, about one third of pregnant women who consume alcohol engage in binge drinking. Among all women who reported binge drinking, pregnant women reported a higher frequency of binge drinking than non-pregnant women. One possible reason might be that women who binge drink during pregnancy are more likely to be alcohol-dependent than the average female binge drinker, and therefore binge drink more frequently. A recent U.S. study found that among adult binge drinkers, the prevalence of alcohol dependence increased significantly with the frequency of binge drinking.4 Women who binge drink during pregnancy that are not alcohol-dependent would benefit from alcohol screening and intervention, which involves screening patients using validated questions, followed by a brief counselling intervention to advise patients who screen positive to set goals and take steps toward reducing their alcohol consumption.3,5 Patients with more severe alcohol problems should be referred to specialized care.3

Abstract
What is already known on this topic?
Excessive alcohol use is a risk factor for a wide range of health and social problems including liver cirrhosis, certain cancers, depression, motor vehicle crashes, and violence. Alcohol consumption during pregnancy is also a risk factor for fetal alcohol spectrum disorders (FASDs) and other adverse birth outcomes, making alcohol use during pregnancy a leading preventable cause of birth defects and developmental disabilities. There is no known safe amount of alcohol consumption during pregnancy.
What is added by this report?
Based on 2011–2013 Behavioral Risk Factor Surveillance System data, 1 in 10 (10.2%) pregnant women aged 18–44 years reported consuming alcohol in the past 30 days, and 3.1% reported binge drinking in the past 30 days. Similar to non-pregnant women, about one third of pregnant women who consume alcohol engage in binge drinking. Among binge drinkers, pregnant women reported a statistically significant higher frequency of binge drinking than non-pregnant women.
What are the implications for public health practice?
Implementation of evidence-based strategies would be expected to reduce binge drinking among pregnant women and women of childbearing age, and any alcohol consumption among women who are or might be pregnant. These strategies include alcohol screening and brief intervention as recommended by the U.S. Preventive Services Task Force, and community-level strategies as recommended by the Community Preventive Services Task Force.

Introduction
Alcohol in pregnancy can lead to adverse birth outcomes, including fetal alcohol spectrum disorders (FASDs).1 Community studies estimate that 2% to 5% of first grade students in the United States might have an FASD, which include physical, behavioral, or learning impairments.2 In 2005, the Surgeon General reissued an advisory† urging women who are or might be pregnant to abstain from alcohol consumption to eliminate the risk for FASDs or other negative birth outcomes. In 2011-2013, Behavioral Risk Factor Surveillance System (BRFSS) data, which is a state-based, random-digit–dialed telephone survey1 of the non-institutionalized U.S. population aged ≥18 years, estimated that among pregnant women aged 18–44, 10.2% and 3.1% consume alcohol and binge drink respectively. Among non-pregnant women, 53.6% and 18.2% (95% confidence interval [CI]) consumed alcohol and binge drink respectively. This data was collected from all 50 states from 206,481 women with different ages, ethnicities, sociodemographic and educational backgrounds and employment and marital status, 8,383 (4.0%) of whom were pregnant at the time of interview. The median response rate** among states ranged from 45.2% to 49.7%. Adjusted prevalence ratios (aPRs) and CIs were calculated using logistic regression analysis to examine the association between the prevalence of the two drinking patterns and sociodemographic characteristics, while controlling for the other sociodemographic characteristics. Finally, among women who reported binge drinking, frequency and intensity were estimated. Frequency and intensity across sociodemographic characteristics could only be estimated for non-pregnant women who reported binge drinking. Data were weighted to represent state-level population estimates and aggregated to represent a nationwide estimate. Analyses using SUDAAN 11.0 accounted for the complex sampling design. Among non-pregnant women, the prevalence of any alcohol use was 53.6% and the prevalence of binge drinking was 18.2% (Table 1). Among pregnant women, the prevalence of any alcohol use was 10.2% and the prevalence of binge drinking was 3.1% (Table 2). Implementation of evidence-based clinical and community-level strategies could reduce binge drinking among women who are or might be pregnant and women of childbearing age. Healthcare professionals can support these efforts through alcohol screening and interventions in their primary care practices, clarifying that there is no known safe level of alcohol consumption during pregnancy.3

Pregnant women aged 35-44 reported a significantly higher prevalence of any alcohol use (18.6%) than all other age groups. The prevalence of any alcohol use was twice as high among pregnant women with a university degree than those with a high school diploma or less (aPR = 2.1), and was 2.4 times higher among non-married women than married women. The prevalence of binge drinking among non-married pregnant women was 4.6 times the prevalence among married pregnant women.
Although the overall prevalence of binge drinking was higher among non-pregnant women, pregnant women reported an average of 4.6 binge drinking episodes in 30 days, which was significantly higher than the average 3.1 reported by non-pregnant women (p = 0.044); the intensity of binge drinking was not significantly higher among pregnant women (7.5 drinks) than non-pregnant women (6.0 drinks). Non-pregnant women aged 18-20 years reported the highest frequency (3.9 episodes) and intensity (7.1 drinks) of binge drinking (Table 3)

 

Discussion

In 2011–2013, 1 in 10 pregnant women reported consuming alcohol in a 30-day period and 1 in 33 reported binge drinking; similar to non-pregnant women, about one third of pregnant women who consume alcohol engage in binge drinking. Among all women who reported binge drinking, pregnant women reported a higher frequency of binge drinking than non-pregnant women. One possible reason might be that women who binge drink during pregnancy are more likely to be alcohol-dependent than the average female binge drinker, and therefore binge drink more frequently. A recent U.S. study found that among adult binge drinkers, the prevalence of alcohol dependence increased significantly with the frequency of binge drinking.4 Women who binge drink during pregnancy that are not alcohol-dependent would benefit from alcohol screening and intervention, which involves screening patients using validated questions, followed by a brief counselling intervention to advise patients who screen positive to set goals and take steps toward reducing their alcohol consumption.3,5 Patients with more severe alcohol problems should be referred to specialized care.3 Since previous research found no significant difference in binge drinking frequency between pregnant and non-pregnant binge drinkers, future surveillance should monitor the frequency of binge drinking to see if this pattern persists.6 Consistent with previous reports, the prevalence of alcohol consumption among pregnant women was higher among those with a university degree than among those with less education.6 This might be related to higher discretionary income among women with university degrees, or social acceptability of alcohol consumption and binge drinking established during university years, or a combination of these or other determinants. The prevalence of any alcohol use and binge drinking among pregnant and non-pregnant women in this study is slightly higher than estimates reported from 2006–2010. The differences in estimates between the two periods are likely related to methodological changes in the BRFSS in 2011, rather than actual shifts in the prevalence of alcohol use.7 The BRFSS began sampling respondents using cellular phones in addition to landline phones, and changed the weighting method from poststratification to “raking” (iterative proportional fitting). These changes have been associated with a higher estimated prevalence of excessive alcohol use among U.S. adults.

The findings in this study are subject to at least five limitations:

1. Self-reported alcohol use is generally underreported8
2. Pregnancy status might also have been underreported because a majority of women do not recognize they are pregnant until at least 4 weeks’ gestation.9
3. Some prevalence estimates and ratios of binge drinking among pregnant women had to be suppressed because of unreliable estimates (relative standard errors >0.3).
4. The results could be subject to selection bias since the median response rate was <50% for all 3 years.
5. Changes in BRFSS methodology in 2011 did not allow estimates from 2011–2013 to be compared with estimates from earlier years.

There is a need for a comprehensive approach to reduce alcohol use and binge drinking among pregnant women, and binge drinking among women of childbearing age. Healthy People 2020 established objectives††i to increase the percentage of pregnant women reporting abstinence from any alcohol use to 98% (MCH 11.1), and to increase the percentage reporting abstinence from binge drinking to 100% (MCH 11.2). The Community Preventive Services Task Force recommends several population-level strategies for reducing excessive alcohol consumption and related harms, including the limitation of alcohol outlet density (the number of places in a given area where alcohol may be legally sold for onsite consumption), holding alcohol retailers liable for harms related to the sale of alcohol to minors and intoxicated patrons (dram shop liability), and increasing alcohol taxes.10 The U.S. Preventive Services Task Force also recommends alcohol screening and intervention in primary care settings for persons aged ≥18 years, including pregnant women.5 In addition, CDC funded and is working with Fetal Alcohol Spectrum Disorders Practice and Implementation Centers and National Partners2 to promote system-level practice changes among providers, through training and implementation of evidence-based FASD prevention approaches. Adopting this comprehensive approach to reduce excessive alcohol use among pregnant women and women of childbearing age is an important step toward achieving the Healthy People 2020 objectives of reducing alcohol use among pregnant women, and ultimately reducing FASDs and other alcohol-related adverse birth outcomes.

Acknowledgments

Behavioral Risk Factor Surveillance System state coordinators. Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee.

1. World Health Organization. Global status report on alcohol and health 2014. Geneva, Switzerland: Available at http://apps.who.int/iris/bitstream/10665/112736/1/9789240692763_eng.pdf.
2. May PA, Baete A, Russo J, et al. Prevalence and characteristics of fetal alcohol spectrum disorders. Pediatrics 2014;134:855–66.
3. McKnight-Eily LR, Liu Y, Brewer RD, et al. Vital signs: communication between health professionals and their patients about alcohol use—44 states and the District of Columbia, 2011. MMWR Morb Mortal Wkly Rep 2014;63:16–22.
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5. US Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: US preventive services task force recommendation statement. Ann Intern Med 2013;159:210–8.
6. CDC. Alcohol use and binge drinking among women of childbearing age—United States, 2006–2010. MMWR Morb Mortal Wkly Rep 2012;61:534–8.
7. CDC. Methodologic changes in the Behavioral Risk Factor Surveillance System in 2011 and potential effects on prevalence estimates. MMWR Morb Mortal Wkly Rep 2012;61:410–3.
8. Nelson DE, Naimi TS, Brewer RD, Roeber J. US state alcohol sales compared to survey data, 1993–2006. Addiction 2010;105:1589–96.
9. Floyd RL, Decouflé P, Hungerford DW. Alcohol use prior to pregnancy recognition. Am J Prev Med 1999;17:101–7.
10. Task Force on Community Prevention Services. Preventing excessive alcohol consumption. In: The guide to community preventive services. New York, NY: Oxford University Press; 2005. Available at http://www. thecommunityguide.org/alcohol/index.html.

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