Research Update

Alcohol Use and Pregnancy: An Important Canadian Public Health and Social Issue

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7.2 Identifying Pregnant Women with Substance Use Problems

There is a broad consensus among experts that primary care settings provide an optimal environment for screening pregnant women for alcohol use as part of routine prenatal health care.^165,166 There are many barriers to the implementation of routine screening of all pregnant women; however, it is critical that decisions to screen not be left to individual discretion.¹⁶⁷ Some persons may not acknowledge alcohol use problems due to lack of motivation or fear of discrimination by health care providers, and some providers feel similarly hesitant in raising the issue. This discomfort for both parties is best addressed by creating a non-judgmental, respectful environment in which alcohol screening questions are asked within a general health inquiry and by providing physicians with more information on available pregnancy outreach and treatment programs. Screening for impoverished women who are street involved may be more effective in an outreach environment where there is a health or social work practitioner on staff whom the women trust.¹⁶⁸

Learning about a woman's alcohol use is as simple as having a conversation, perhaps within the context of general health and well-being. An efficient alternative is to use a brief questionnaire. Brief screening instruments are simple, easy-to-use tools that are primarily used in health care settings – an obstetric clinic is ideal – but others in the health and social services can administer them or help the person to complete the questions.

A limitation of screening tools is the tendency of respondents to under-report their use of alcohol. To minimize under-reporting, the T-ACE and TWEAK do not ask women about actual quantities of alcohol used or about current use. Because the TWEAK and T-ACE do not ask for quantities and because that is important information, Hankin and Sokol suggest following up these screens with women whose responses suggest alcohol problems and, with sensitivity, ask about current and at-conception amounts of alcohol used.¹⁷⁴

Whichever method is used, it is critical that it occur in a supportive milieu that is sensitive to the circumstances of pregnant women, particularly substance users. A respectful, non-judgmental approach permits both open questions and increases the likelihood of honest responses.¹⁷⁵ In a study with British Columbia women, Ling found that pregnant women's self-reports of their substance use were quite accurate (as determined by meconium testing of the infant) when they were approached in a nonjudgmental way and were given information that would help them care for themselves and their child.¹⁷⁶ Further, repeated screening (i.e. during each prenatal visit) has been suggested to lead to a growing rapport and therefore more openness, accuracy and opportunity for intervention. Some additional time must be found to raise alcohol use in this context, but it has been argued that it is an efficient way to address questions or complications that may otherwise arise later during the pregnancy.¹⁷⁷

Biomarkers (e.g. meconium, carbohydrate-deficient transferrin [CDT] and gamma glutamyl transpeptidase [GGT]) are an alternative to asking questions about alcohol use or using questionnaires to screen for alcohol problems. To their advantage, they can be administered in a (physically) non-intrusive manner and measure current and recent use rather than historical use patterns. However, ethical concerns arise regarding the administration of any test that can be applied without the woman's knowledge or consent, and this is particularly the case with the use of bio-markers. For this reason, further research and an associated inclusive social and legal-ethical policy debate is needed before the routine use of laboratory tests can be recommended to identify alcohol risk among pregnant women.^178-180 Screening for pregnant women who consume alcohol, of course, presupposes that intervention resources are available to support identified women. Although there are no empirical data to support this, experts generally agree that resources to care for and treat pregnant women with substance use issues are quite insufficient in this country.

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