Research Update

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

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7.3 Brief Interventions

If, through conversation or completion of a screening questionnaire, it appears that a pregnant woman may have alcohol use issues, a more complete assessment is in order. A viable option for persons who are not alcohol dependent and have reasonable social support is a brief intervention (one to three sessions) conducted by a health care or social services practitioner.¹⁸¹ In a review of brief interventions, Yahne and Miller¹⁸² summarized the elements of successful interventions, identified by the acronym FRAMES:

• Feedback: Provide clients with personal feedback regarding their individual status.
• Responsibility: Emphasize personal responsibility for change and the individual's freedom of choice.
• Advice: Include a clear recommendation or advice on the need for change, typically in a supportive rather than authoritarian manner.
• Menu: Offer a menu of different strategies for change, providing options from which clients may choose what seems sensible to them.
• Empathy: Place emphasis on an empathetic, reflective, warm and supportive practitioner style, which is linked with positive treatment outcomes.
• Self-efficacy: Reinforce self-efficacy – the client's expectation that she can change.

Insight: Time Is of the Essence

Brief physician-led alcohol-focused interventions – 10 to 15 minutes –following the FRAMES model have been shown to be effective with various populations.¹⁸³ There is now good evidence that a brief intervention can be effective for non-dependent women of childbearing age. Brief interventions have also been shown to reduce alcohol consumption among pregnant drinkers who were not alcohol dependent.

In a well-designed experimental study, Manwell et al. tested an intervention for women of childbearing age who were not seeking treatment. The intervention consisted of two 15- minute physician-delivered sessions scheduled one month apart (consisting of advice, education and contracting, using a workbook). Patients received a follow-up phone contact by a clinic nurse within two weeks of each physician session. The intervention was conducted by 64 community-based physicians who were trained using role play and general skills training techniques. The sample consisted of women ages 18 to 40 who consumed at least 11 drinks a week, 4 drinks per occasion or scored greater than 2 on the CAGE.^xxvi When followed up after 48 months (which is an unusually lengthy duration in the literature), those receiving the intervention reduced their alcohol intake by 48% on average (from 14 to 7.5 drinks per week). The number of subjects reporting any binge drinking declined from 93% to 68%, while the number of binge drinking episodes in the previous month decreased from five to three.¹⁸⁴

Chang et al. tested a two-session intervention with pregnant women that focused on identifying alcohol use goals during pregnancy and found that the intervention assisted in the reduction of alcohol use.¹⁸⁵ Hankin et al. conducted a randomized controlled trial to examine the effect of a brief intervention strategy on drinking in subsequent pregnancies. Upon follow-up, women in the experimental group were found to have consumed slightly more than half as much as women in the control condition. Women who reported the heaviest pre-pregnancy drinking showed the largest reduction in drinking following the brief intensive intervention, and children born to women in the brief intensive intervention groups showed better growth outcomes at birth.¹⁸⁶

Motivational interviewing (MI), as conceived by Miller and Rollnick,¹⁸⁷ has shown some effectiveness as a brief intervention with pregnant women.¹⁸⁸ Handmaker et al. tested a brief MI intervention with a small sample of drinking pregnant women in a prenatal care setting.¹⁸⁹ After an assessment, those in the experimental sample participated in a one-hour intervention consisting of a discussion of what the woman already knew about the effects of drinking, feedback on the severity of her drinking, and comments intended to increase motivation to change. Those in the control condition were given the assessment and mailed information on potential risks associated with drinking during pregnancy. Women who had been reaching high blood alcohol concentrations (BACs) before the intervention were found to be drinking at much lower BAC levels compared with women in the control group. A large feasibility study by the US Centers for Disease Control (CDC) has shown that a relatively brief (five session) MI intervention can be successful in effecting change with higher risk women. This study found that motivational counselling, focusing on both reducing risk drinking and using contraception, is feasible and promising for women at high risk for an alcohol-exposed pregnancy.¹⁹⁰ The intervention consisted of four motivational counselling sessions conducted by a mental health clinician and one familyplanning consultation by a family-planning clinician. Discussions in each session were tailored to each woman's self-rated readiness to change and interest in discussing alcohol use or contraception. In brief, the intent was to provide brief advice and counselling for moderate-to-heavy drinkers to reduce their drinking levels or referral to community treatment services for alcohol-dependent drinkers.

It was found that the option of having two choices for achieving positive outcomes appeared to be appealing, supporting the contention that people are more committed to goals that they establish for themselves. Approximately one in four women chose the option of effective contraception as their principal step in reducing their risk for an alcohol-exposed pregnancy; 12% reduced their drinking only; while close to one-third reported both. Lower risk women (in terms of their scores on an alcohol use questionnaire) were the most likely to reduce their risk for an alcohol-exposed pregnancy, but least likely to do so through reducing their alcohol use (i.e. they tended to do so through instituting effective contraception use). These encouraging results were consistent across six community sites in various parts of the US. However, it will be important to study the model using an experimental design to increase confidence in its effectiveness, which is the intention of the CDC. A modification of this methodology is currently being tested with adolescent women; Project Balance (Birth Control and Alcohol Awareness: Negotiating Choices Effectively) is underway with college women in the southeast US.¹⁹¹

It appears that any constructive attention to this issue will help non-dependent women to make changes. The vast majority of women, upon learning they are pregnant or when planning a pregnancy, are able to stop drinking on their own.¹⁹² For others, having the screening questionnaire administered in a respectful, non-judgmental way seems to raise awareness sufficiently to instigate change.¹⁹³ Aside from a basic understanding that nondependent drinkers tend to respond better to brief interventions than dependent persons, a need remains for research on how different women respond to various levels of intervention. In light of this, Handmaker et al. suggested that providers employ brief interventions within a stepped care approach for pregnant women with alcohol use issues.^194,195 In this stepped care model, clients are assessed according to level of motivation, self-efficacy, level of dependence, co-morbidity and sociocultural factors, and triaged into one of three treatment levels. A guiding principle of this model is the use of the least intensive (and least expensive) level first and “stepping up” a client if the less intensive treatment has not been effective.

It is also important to note that, although a biological effect on fetal development associated with a father's drinking has been suggested, its actual presence and role has not been demonstrated^196,197; consequently, the male's role in the development of birth defects appears to be primarily through social and psychological influence. However, this influence appears to be quite strong, with various studies showing drinking by a partner to be associated with use by the pregnant woman.¹⁹⁸ Consequently, although there is no empirical evidence one way or another, it is reasonable to direct attention to drinking fathers to enlist them in supporting their partner toward healthy choices.

xxvi. The CAGE is a 4-question questionnaire that screens for alcohol problems, asking whether a person has ever tried to CUT BACK, been ANNOYED by the criticism of others over their drinking, felt GUILTY about their drinking, or drank first thing in the morning (EYEOPENER).

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