Discordance Between Perinatal Alcohol Use Among Women and Provider Counseling for Alcohol Use: An Assessment of the Pregnancy Risk Assessment Monitoring System

Abstract

Objective

In the United States, guidelines indicate all pregnant women should be screened for and counseled on alcohol use to prevent adverse perinatal outcomes due to alcohol consumption. The objective of this study was to describe sociodemographic factors associated with receipt of prenatal alcohol counseling and perinatal alcohol use among US women.

Methods

State health departments collected data for the Pregnancy Risk Assessment Monitoring System Phase 7 during 2012-2015, and we restricted the sample to a complete case analysis (N = 135 111). The 3 dichotomous outcomes were preconception alcohol use (3 months before pregnancy), prenatal alcohol use (during last 3 months of pregnancy), and prenatal alcohol counseling. Predictor variables were age, race, Hispanic ethnicity, education, marital status, health insurance status, and previous live births. We estimated survey-weighted logistic regression models for each outcome.

Results

Half (56.0%) of pregnant women reported preconception alcohol use, 70.5% received prenatal alcohol counseling, and 7.7% reported prenatal alcohol use during the last 3 months of pregnancy. Black women were significantly less likely than White women (odds ratio [OR] = 0.49; 95% CI, 0.46-0.52) and Hispanic women were significantly less likely than non-Hispanic women (OR = 0.62; 95% CI, 0.58-0.66) to report preconception alcohol use. We found similar patterns for prenatal alcohol use among Black women. Black women were significantly more likely than White women (OR = 1.66; 95% CI, 1.55-1.77) and Hispanic women were significantly more likely than non-Hispanic women (OR = 1.51; 95% CI, 1.40-1.61) to receive prenatal alcohol counseling. We found similar patterns for age, education, and health insurance status.

Conclusion

Disparities in alcohol counseling occurred despite the national recommendation for universal screening and counseling prenatally. Continued integration of universal screening for alcohol use during pregnancy is needed.

Keywords

alcohol counseling guidelines PRAMS preconception prenatal

According to 2011-2013 national data, an estimated 53.6% of nonpregnant women aged 18-44 reported any alcohol use, and 18.2% reported heavy episodic drinking in the past 30 days (≥4 drinks for women in about 2 hours).^1,2 Women are recommended to not consume alcohol while pregnant. Notably, during 2015-2017, pregnant women who reported any heavy episodic drinking in the past 30 days reported an average of 4.5 episodes of heavy drinking.³ During pregnancy, an estimated 11.5% of pregnant women reported current drinking and 3.9% of pregnant women reported current episodes of heavy drinking.³ In addition, among women who report alcohol use during pregnancy, most women typically report use during the first trimester.⁴

Alcohol exposure during pregnancy is associated with adverse outcomes, including fetal alcohol spectrum disorder.⁵ Research indicates that engaging in regular heavy drinking puts a fetus at the greatest risk for severe problems, but that even lesser amounts can cause damage.^6
-8 As such, the American College of Obstetricians and Gynecologists recommends screening for alcohol use during the first trimester of pregnancy.⁹ In addition, the US Preventive Services Task Force recommends screening for unhealthy alcohol use in primary care settings for adults and engaging in brief counseling for hazardous drinking.¹⁰ This recommendation includes the preconception period. A life course perspective for healthy birth outcomes includes considering the preconception and prenatal periods,¹¹ especially because approximately half of all pregnancies in the United States are unintended.¹²

Despite the recommendations for alcohol screening among pregnant women, evidence suggests that screening is not regularly implemented. For example, research among a sample of pregnant women in Maryland demonstrated that many women reported not being asked about alcohol use during pregnancy.¹³ Among health care providers, a 2014 survey indicated that only 35.2% of respondents reported screening to assess patient alcohol use and 23.3% reported using a screening tool, few of which were validated screening tools recommended for use among pregnant women.¹⁴

Because health care providers play a critical role in screening and counseling on alcohol use during the perinatal period, it is important to examine which women are using alcohol during the perinatal period and which women are reporting guidance from a health care provider. The objective of this study was to describe sociodemographic factors associated with receipt of prenatal alcohol counseling and perinatal alcohol use among US women.

Methods

Sample

This was a secondary analysis of data from the Pregnancy Risk Assessment Monitoring System (PRAMS) Phase 7, which were collected during 2012-2015. Briefly, PRAMS is a state-level, population-based surveillance system that samples women 2-6 months after a live birth using the birth certificate as the sampling frame. Subpopulations of women are oversampled, including racial/ethnic minority groups and women giving birth to an infant with a low birth weight.¹⁵ PRAMS collected data from 47 states and 4 additional jurisdictions; however, the sample for our study included 36 jurisdictions that met the PRAMS requirement for a 65% response rate. The following jurisdictions were included in our study: Alaska, Alabama, Arkansas, Colorado, Connecticut, Delaware, Georgia, Hawaii, Illinois, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, New Hampshire, New Jersey, New Mexico, New York, New York City, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming. States and jurisdictions can select their recruitment and data collection strategies, but all data are collected via mail and telephone surveys. The analytic research file for PRAMS Phase 7 included 147 747 responses, and we restricted the sample to a complete case analysis with 135 111 (91.4%) postpartum women. This study was considered exempt by the North Texas Regional Institutional Review Board.

Measures

We used 3 outcome measures for this study: preconception alcohol use, prenatal alcohol use, and prenatal alcohol counseling. We measured preconception alcohol use using the question, “During the 3 months before you got pregnant, how many alcoholic drinks did you have in an average week?” We measured prenatal alcohol use using the question, “During the last 3 months of your pregnancy, how many alcoholic drinks did you have in an average week?” We dichotomized responses for both questions to be drinking during the preconception and prenatal periods or did not drink. We measured prenatal alcohol counseling using the question, “During any of your prenatal care visits, did a doctor, nurse, or other health care worker talk with you about any of the things lists below? How drinking alcohol during pregnancy could affect my baby.” Participants responded yes or no to this question.

Predictor variables were sociodemographic characteristics from the birth certificate file: age (≤19, 20-24, 25-29, 30-34, ≥35), race (White, Black, “other”), Hispanic ethnicity (Hispanic, non-Hispanic), education (<12 years, 12 years, 13-15 years, ≥16 years), marital status (married, not married), health insurance status (Medicaid, non-Medicaid, no health insurance), and previous live births (none, ≥1).

Data Analysis

We conducted all analyses using SAS version 9.4 (SAS Institute Inc) and survey-weighting procedures to account for the complex sample design of the survey. We used an alpha level of 0.05 to determine significance. We estimated survey-weighted descriptive statistics for all variables. We estimated 3 binary logistic regression models for each respective outcome. These models included all sociodemographic variables. In addition, we adjusted the model for prenatal alcohol use for prenatal alcohol counseling, and we adjusted the model for counseling during pregnancy for preconception alcohol use. Only 2.3% of women who drank during pregnancy did not report drinking in the preconception period; therefore, we did not include preconception alcohol use in the prenatal alcohol use model. We estimated adjusted odds ratios (aORs) and 95% CIs.

Results

Of 135 111 postpartum participants, 56.0% reported preconception alcohol use, 70.5% reported receiving prenatal alcohol counseling, and 7.7% reported prenatal alcohol use (Table 1). About half of the sample was aged 20-29, and more than half had >high school education. Most women were White, were non-Hispanic, were married, had ≥1 previous live birth, and had non-Medicaid health insurance.

Table 1

Frequencies and survey-weighted proportions for preconception alcohol use, counseled for alcohol use during pregnancy, and prenatal alcohol use, PRAMS Phase 7, 2012-2015 (N = 135 111)^a

Variable	Preconception alcohol use, weighted %	Prenatal alcohol counseling, weighted %	Prenatal alcohol use, weighted %	Total no. (%)
Total, no. (weighted %)	72 216 (56.0)	97 182 (70.5)	9289 (7.7)	135 111 (100.0)
Age, y
≤19	28.2	85.3	2.6	9172 (6.0)
20-24	51.8	79.6	4.6	29 078 (20.7)
25-29	58.5	70.9	6.6	38 905 (29.5)
30-34	62.2	64.8	10.3	36 828 (27.8)
≥35	56.6	62.2	11.4	21 128 (16.0)
Race
White	62.2	68.1	8.6	82 758 (71.8)
Black	44.6	81.1	5.6	23 571 (13.8)
Other	35.9	72.3	5.5	28 782 (14.3)
Ethnicity
Hispanic	37.2	79.1	5.8	22 412 (16.8)
Non-Hispanic	59.8	68.8	8.1	112 699 (83.2)
Education, y
<12 (<high school)	26.7	80.2	3.8	19 392 (13.3)
12 (high school degree)	46.9	76.8	4.7	33 820 (24.2)
13-15 (some college)	61.0	71.1	6.2	39 145 (28.0)
≥16 (college degree)	69.7	61.8	12.6	42 754 (34.5)
Marital status
Married	58.7	64.3	9.1	80 201 (61.6)
Not married	51.8	80.5	5.5	54 910 (38.4)
Health insurance
Medicaid	43.5	78.2	4.7	50 080 (37.0)
Non-Medicaid	65.4	65.2	9.7	61 838 (52.1)
None	53.6	70.0	8.6	23 193 (10.9)
Previous live birth
≥1	51.9	65.7	7.6	80 104 (59.8)
None	62.1	77.6	7.9	55 007 (40.2)

^aPregnancy Risk Assessment Monitoring System 2012-2015.¹⁵

Preconception Alcohol Use

Compared with women aged 20-24, women aged ≤19 were less likely and women aged ≥25 were more likely to report preconception alcohol use (Table 2). The likelihood of reporting preconception alcohol use was lower among Black women (aOR = 0.49; 95% CI, 0.46-0.52) and women of other races (aOR = 0.40; 95% CI, 0.38-0.42) than among White women; among Hispanic women than among non-Hispanic women (aOR = 0.62; 95% CI, 0.58-0.66); among married women than among unmarried women (aOR = 0.55; 95% CI, 0.52-0.58); among women with Medicaid (aOR = 0.66; 95% CI, 0.63-0.69) and women without health insurance (aOR = 0.78; 95% CI, 0.74-0.82) than among women with non-Medicaid health insurance; and among women with ≥1 previous live birth than among women with no previous live birth (aOR = 0.64; 95% CI, 0.62-0.67). In addition, women with <high school education were less likely and women with >high school education were more likely to report preconception alcohol use than women with a high school education.

Table 2

Adjusted odds ratios (95% CIs) for preconception alcohol use, counseled for alcohol use during pregnancy, and prenatal alcohol use, PRAMS Phase 7, 2012-2015 (N = 135 111)^a

Variable	Preconception alcohol use^b	Prenatal alcohol counseling^c	Prenatal alcohol use^d
Age, y
≤19	0.41 (0.37-0.46)	0.99 (0.87-1.12)	0.63 (0.49-0.80)
20-24	1 [Reference]	1 [Reference]	1 [Reference]
25-29	1.18 (1.12-1.26)	0.88 (0.82-0.93)	1.18 (1.04-1.32)
30-34	1.28 (1.20-1.36)	0.80 (0.75-0.86)	1.64 (1.46-1.84)
≥35	1.08 (1.01-1.16)	0.73 (0.68-0.79)	1.90 (1.67-2.15)
Race
White	1 [Reference]	1 [Reference]	1 [Reference]
Black	0.49 (0.46-0.52)	1.66 (1.55-1.77)	0.82 (0.74-0.91)
Other	0.40 (0.38-0.42)	1.08 (1.02-1.14)	0.66 (0.60-0.73)
Ethnicity
Hispanic	0.62 (0.58-0.66)	1.51 (1.40-1.61)	1.03 (0.92-1.16)
Non-Hispanic	1 [Reference]	1 [Reference]	1 [Reference]
Education, y
<12 (<high school)	0.54 (0.50-0.58)	1.14 (1.05-1.24)	0.87 (0.74-1.03)
12 (high school degree)	1 [Reference]	1 [Reference]	1 [Reference]
13-15 (some college)	1.56 (1.48-1.65)	0.84 (0.80-0.89)	1.18 (1.06-1.32)
≥16 (college degree)	2.10 (1.98-2.23)	0.71 (0.67-0.76)	2.11 (1.89-2.35)
Marital status
Married	0.55 (0.52-0.58)	0.71 (0.68-0.75)	0.88 (0.81-0.96)
Not married	1 [Reference]	1 [Reference]	1 [Reference]
Health insurance
Medicaid	0.66 (0.63-0.69)	1.26 (1.19-1.32)	0.81 (0.74-0.89)
Non-Medicaid	1 [Reference]	1 [Reference]	1 [Reference]
None	0.78 (0.74-0.82)	1.04 (0.98-1.10)	1.06 (0.97-1.16)
Previous live birth
≥1	0.64 (0.62-0.67)	0.56 (0.54-0.59)	0.90 (0.84-0.97)
None	1 [Reference]	1 [Reference]	1 [Reference]
Preconception alcohol use
Yes	—	1.21 (1.16-1.26)	—
No	—	1 [Reference]	—
Counseled on alcohol use
Yes	—	—	1.02 (0.95-1.10)
No	—	—	1 [Reference]

^aPregnancy Risk Assessment Monitoring System 2012-2015.¹⁵

^bAdjusted for age, race, Hispanic ethnicity, education, marital status, health insurance status, and previous live birth.

^cAdjusted for age, race, Hispanic ethnicity, education, marital status, health insurance status, previous live birth, and preconception alcohol use.

^dAdjusted for age, race, Hispanic ethnicity, education, marital status, health insurance status, previous live birth, and counseling on alcohol use during pregnancy.

Prenatal Counseling on Alcohol Use

Women who were less likely to report being counseled on alcohol use during pregnancy were older (aged ≥25 vs aged 20-24) and had higher educational attainment (>high school education vs high school education) (Table 2). Similarly, women were less likely to report being counseled on alcohol use during pregnancy if they were married vs not married (aOR = 0.71; 95% CI, 0.68-0.75) and had a previous live birth vs no previous live birth (aOR = 0.56; 95% CI, 0.54-0.59). In contrast, being counseled on alcohol use during pregnancy was more likely among women who were Black (aOR = 1.66; 95% CI, 1.55-1.77) or of another race (aOR = 1.08; 95% CI, 1.02-1.14) than among White women; among Hispanic women than among non-Hispanic women (aOR = 1.51; 95% CI, 1.40-1.61); among women with <high school education than among women with a high school education (aOR = 1.14; 95% CI, 1.05-1.24); among women who had Medicaid than among women with non-Medicaid health insurance (aOR = 1.26; 95% CI, 1.19-1.32); and among women who reported preconception alcohol use than among women who reported no preconception alcohol use (aOR = 1.21; 95% CI, 1.16-1.26).

Prenatal Alcohol Use

The odds ratios for prenatal alcohol use were similar to the odds ratios of preconception alcohol use, with some exceptions. Hispanic ethnicity, having <high school education, and having ≥1 previous live birth were not significant for prenatal alcohol use. In addition, being counseled during pregnancy was not significantly associated with alcohol use during the prenatal period. Women were less likely to report prenatal alcohol use if they were aged ≤19 vs aged 20-24 (aOR = 0.63; 95% CI, 0.49-0.80), were Black (aOR = 0.82; 95% CI, 0.74-0.91) or other race (aOR = 0.66; 95% CI, 0.60-0.73) vs White, were covered by Medicaid vs not covered by Medicaid (aOR = 0.81; 95% CI, 0.74-0.89), and had a previous live birth vs no previous live birth (aOR = 0.90; 95% CI, 0.84-0.97). Women aged ≥25 and who had >high school education were more likely to consume alcohol during pregnancy than women aged 20-24.

Discussion

This study sought to describe sociodemographic correlates to preconception alcohol use, prenatal alcohol use, and prenatal alcohol counseling among a sample of postpartum women. Approximately half of women reported preconception alcohol use, 30% of women reported not receiving any health care provider counseling on alcohol use during pregnancy, and about 8% reported prenatal alcohol use. Overall, women who were most likely to consume alcohol in the preconception and prenatal periods were the least likely to report receiving prenatal alcohol counseling, despite recommendations for universal screening.¹⁵

Our findings support previous research reporting differences in the demographic and social characteristics of women receiving preconception counseling or other medical services. For example, a study of 197 women in Massachusetts found that women with public health insurance were less likely to receive preconception counseling than privately insured women.¹⁶ In Maryland, a study of 3043 women found that women with a previous full-term birth were less likely than women with a previous preterm birth or no live birth to receive preconception counseling.¹⁷ Studies of implicit bias association tests among clinicians working in internal medicine showed that, despite reports of no explicit preference for White vs Black patients, unconscious racial biases may influence the use of medical procedures.¹⁸ Such biases were illustrated in the racial discrepancies found in a study of 380 women in Florida, where Black and White women were statistically similar in their positive test results for cocaine use, yet Black women were subsequently reported to authorities at approximately 10 times the rate of White women.¹⁹ Ideologies that foster disparate treatment on the basis of social constructs such as race and income have far-reaching implications and are a threat to societal aims of reproductive justice.²⁰

Our findings have important implications to reduce prenatal alcohol use. First, this study supports the need for universal prevention with screening for any alcohol use to occur among pregnant women,²¹ not screening on the basis of demographic characteristics. Our study found differences in many demographic constructs that, if used to determine who should or should not receive interventions, would likely miss women in need of intervention. In addition, previous research showed health care provider bias in intervention delivery based on health care provider beliefs about the safety of alcohol use during pregnancy.¹⁴ Similar to a 2019 study by Chiodo et al,¹⁴ our findings showed potential health care provider bias in another form: women who were most likely to consume alcohol during the perinatal period were less likely to report being counseled on alcohol use. Thus, public health agencies and clinics should consider screening and interventions that reduce the opportunity for health care provider bias to occur. For example, research has shown the feasibility of online screeners for prenatal alcohol use,^22,23 which would remove health care provider bias in the screening process. However, current prenatal screening questionnaires show modest performance when screening alcohol use and substance use, which should be considered screening for risk and/or delivering an indicated intervention.^22,23 The results from our analysis found that prenatal counseling on alcohol use was not associated with alcohol use during the last 3 months of pregnancy. Because universal screening is recommended, research should increase performance of screening questionnaires in modes of delivery (eg, online screeners) that reduce the opportunity for health care provider bias.

Moreover, because rates of prenatal alcohol use are problematic, intervention efforts should continue to focus on reducing preconception alcohol use. The best predictor of behavior is past behavior; thus, reducing preconception alcohol use may also reduce prenatal alcohol use. Efficacious interventions to reduce alcohol-exposed pregnancies, such as CHOICES,²⁴ should be implemented without bias to women. Research should continue to develop efficacious online versions of CHOICES or similar interventions to screen and deliver unbiased health care provider interventions.²⁵

Limitations

This study had several limitations. First, data on alcohol use during the preconception and prenatal periods were self-reported and may have been affected by participant recall. Moreover, the measure of alcohol use was dichotomized as presence or absence, to overcome problems of respondents’ recalling the frequency of alcohol use, drink size, number of standard drinks consumed, and the small numbers of women who reported high levels of alcohol use. Third, the outcome for counseling on alcohol use during pregnancy may not have captured data on screening and brief counseling on alcohol during pregnancy or may not have been recalled by women during the postpartum period. Fourth, the question on prenatal alcohol use was limited to the last 3 months of pregnancy, whereas the period of greatest risk for adverse effects is early pregnancy. Fifth, PRAMS includes data on women who had a live birth; as such, the sample may be biased toward healthy women. Selection bias may be present because women with heavy prenatal alcohol consumption are at an increased risk of being excluded from the sample of live births due to adverse pregnancy outcomes (eg, stillbirth, miscarriage).²⁶ Finally, these results are generalizable to the states and jurisdictions that released data for PRAMS Phase 7; as such, they may not be generalizable to all states. However, PRAMS is a nationally recognized survey to assess prenatal health and assess preconception and prenatal alcohol use among women.

Conclusion

Prevention of alcohol-exposed pregnancies requires universal screening during the preconception and prenatal periods. National recommendations encourage standardized screening and counseling during these periods to prevent adverse health outcomes for women and their children. Moreover, universal screening of all women can help disrupt any potential biases in screening for health risk behaviors. Future public health work should focus on integrating universal screening for alcohol use during the preconception and prenatal periods for women.

Footnotes

Acknowledgments

The authors acknowledge the PRAMS Working Group and the Centers for Disease Control and Prevention for making available the data used for this analysis.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Erika L. Thompson, PhD

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