How to

be alcohol­free mothers­to­be.

help your clients or patients

Tips for Providers

on Fetal Alcohol Spectrum Disorders
Share the truth.
 

Alcohol and pregnancy can be an unfortunate mix. Many people don’t

know that like a pregnant woman’s use of tobacco or drugs, her use of

alcohol can hurt her fetus.

The truth is, drinking alcohol while pregnant is risky.

There is no known safe amount of alcohol use during pregnancy.1

Yet, many pregnant women who drink­to­moderate amounts of

alcohol think it cannot harm their babies.

There is no safe type of alcohol to use during pregnancy.A bottle of

beer, a glass of wine, home brew, a“forty,”hard lemonade, or

“alcopops”*—even some energy drinks—all carry the same risk as

drinking a shot of hard liquor or a mixed drink made with liquor.

They all contain about the same amount of alcohol.

There is no safe time to drink alcohol during pregnancy.Drinking

alcohol at any time during pregnancy can permanently damage the

fetal brain and other parts of the body. Some research indicates that

the brain is especially vulnerable to alcohol during the first few

weeks of fetal development.

Because most pregnancies are unplanned,women and girls usually are

not aware that they have become pregnant and may continue to drink

alcoholic beverages.Data on past month alcohol use among women in

the United States, indicate that—

12.2 percent of pregnant women (about one in eight) drank alcohol.

This rate remained stable over the 15­year period 1991–2005. 2

19 percent drank alcohol during their first trimester; 7.8 percent in

the second trimester; and 6.2 percent in the third trimester.3

Many caring professionals, including social workers, doctors, nurses, and

other clinicians do not discourage all drinking by pregnant women,so it is

one reason it is important that you tell your clients that a pregnant

woman or girl who drinks alcoholic beverages can cause damage to her

baby, possibly including fetal alcohol spectrum disorders.

1

National Institute on Alcohol Abuse and Alcoholism.2003.Alcohol:A Women’s Health Issue. NIH Publication No.03­4956.

Rockville,MD:National Institutes of Health.pubs.niaaa.nih.gov/publications/brochurewomen/women.htm.

2

CDC.MMWR Weekly, May 22, 2009,“Alcohol Use Among Pregnant and Nonpregnant Women of Childbearing Age—United

States, 1991–2005.”

3

SAMHSA, Office of Applied Studies. May 21, 2009. The NSDUH Report. Substance Use among Women During Pregnancy and

Following Childbirth. Rockville,MD.

*Alcopops are the popular name for sweetened,flavored alcoholic beverages usually sold in single­serving cans or

bottles.They are the preferred alcoholic beverage of underage girls.Teens also call it“cheerleader beer”and“chick

beer.”
Expose the consequences.
 

Awoman or girl who drinks alcohol during pregnancy risks causing her

child to be born with a fetal alcohol spectrum disorder.

Fetal alcohol spectrum disorders (FASD) is an umbrella term for the range

of abnormal effects that can occur in an individual whose mother drank

alcohol while pregnant.These effects may include physical, mental,

behavioral, and/or learning disabilities with possible lifelong implications.

Research shows that drinking alcohol during pregnancy is the number one

known preventable cause of mental retardation.4

Alcohol is a teratogen—a substance that can cause abnormalities in a

developing fetus. Because alcohol can affect so many sites in the brain and

body, it can cause more harm to the developing fetus than heroin, cocaine,

or marijuana.5

Use of alcohol by a pregnant woman or girl can cause her baby to have

brain damage, defects in internal organs such as the heart or liver,

abnormal facial or physical features, and/or behavioral and learning

disabilities.

4Abel, E.L., and Sokol, R.J. 1987. Incidence of fetal alcohol syndrome and economic impact of FAS­related anomalies.Drug and

Alcohol Dependency 19(1):51­70.

5 Stratton,K.;Howe,C.;.and Battagalia, F., eds. 1996. Fetal alcohol syndrome:Diagnosis, epidemiology, prevention and

treatment. Rockville, MD: National Academy Press. http://books.nap.edu/httm/fetal.
Ask about alcohol use.
 

T

A

C

E

Tools are available to screen for alcohol use,to detect risky drinking, binge

drinking, and alcoholism. Studies have shown that some screening tools

are very effective with women. For instance, you would ask your client:

“I have a few routine questions for you about when you use alcohol. Have you

ever had a drink containing alcohol?”

If she answers“yes,”you might use one of several validated screening

tools,such as the T­ACE and ask:

Tolerance:

How many drinks does it take for you to feel high?

(2 or more drinks = 2 points)

Annoyed:

Have people annoyed you by criticizing your drinking?

(Yes = 1 point)

Cut down:

Have you ever felt you ought to cut down on your drinking?

(Yes = 1 point)

Eye­opener:

Have you ever had an eye­opener (a drink first thing in the morning)

to steady your nerves? (Yes = 1 point)

It takes about 1 minute to ask the T­ACE questions.A score of 2 points or

more may indicate the need for intervention.

Whether a woman or girl is pregnant, not pregnant, or even not trying to

become pregnant, if her T­ACE score is 2 points or more; or if she has more

than 3 standard­sized drinks at one sitting/occasion, or more than 5

standard­sized drinks a week,she is engaging in risky drinking; 4 standardsized drinks at one sitting or 7 drinks a week is binge drinking. If your

conversation reveals either level of drinking,she should be counseled

and/or referred for follow up.

Note: Screening tools also proven to be reliable and valid with women who are pregnant or not pregnant include the 5P’s,

the Alcohol Use Disorder Identification Test (AUDIT), CAGE, and TWEAK. Some of these instruments are available in Spanish

and other languages. For more information,refer to Treatment Improvement Protocol TIP 51, Substance Abuse Treatment:

Addressing the Specific Needs of Women at www.store.samhsa.gov/product/TIP­51­Substance­Abuse­Treatment­Addressingthe­Specific­Needs­of­Women/SMA09­4426).
Help,using proven strategies.
 

*Screening and Brief Intervention (SBI) models in which counselors

have more than one contact with the client have proven effective at

stopping or reducing alcohol use in women and girls,whether pregnant or

not pregnant, in a wide range in age, and from a variety of racial and ethnic

groups,socioeconomic and educational levels, geographic locations, and

substance use status.

One successful SBI model uses a simple written assessment and 10­ to

15­minute intervention with pregnant women who report drinking.This

intervention has been integrated by providers into their existing health

care and social services systems.They are reaching women and girls

through the Women, Infants, and Children (WIC) Program and Healthy Start

programs, as well as community clinics and residential and outpatient

treatment centers.

SBI models have two primary components: an assessment,such as the

T­ACE, and motivational interviewing.

**Motivational interviewing (MI) is not just a counseling technique: It is a

way of relating to your client that can help them resolve their ambivalence

around stopping behaviors they know are dangerous,such as drinking

while pregnant and risky or binge drinking. MI­based interventions—

Focus on client strengths.

Use empathy more than authority.

Recognize co­occurring disorders.

Center the encounter on the individual.

Respect the client’s autonomy.

The keys are to collaborate with rather than confront a client and to forge

mutual understanding;to draw out the client’s true motivations,rather

than impose your assumptions and ideas; and to de­emphasize your

authority and recognize and convey that the client has the power and

responsibility for changing her behavior.

*To obtain information on SBI programs successfully used with pregnant and non­pregnant women and girls, visit

http://www.fasdcenter.samhsa.gov.

**For more information on motivational interviewing,see Enhancing Motivation for Change in Substance Abuse Treatment,

SAMHSA/CSAT TIP Series,No. 35.http://www.ncbi.nlm.nih.gov/books/NBK64967/.
Leverage your relationship.
 

You are a trusted source of advice and information. If you learn that

your client is drinking alcohol, your close relationship makes you a good

person to give advice in a supportive way.Here are some tips for starting

the conversation:

Begin by telling her that you care about her and her baby.

Ease into the subject with talk about plans for the birth,such as

getting a crib, clothes, and toys.

Ask her if she has been to a doctor or clinic for prenatal care and if

she is taking prenatal vitamins, and is following other medical advice.

Tell her that drinking alcohol at any time during her pregnancy can

hurt her unborn baby.Give her important facts:

Any alcohol she drinks goes into her bloodstream and passes to

the unborn baby.

Unborn babies cannot process alcohol as adults can,so ifshe

drinks any alcohol,she risks causing permanent damage to her baby.

Give her the companion booklet for pregnant women and girls.

Ask if there are problems in her life that cause her to want to

drink alcohol.

Offer to find support services to help her stop drinking, if

needed. If she is a heavy drinker, ensure that she stops drinking under

professional supervision.

If your client says she drank during another pregnancy and the baby

was okay,tell her that—

Just because she drank alcohol during a previous pregnancy without

harming the baby,there is no guarantee that she can drink alcohol

and not affect the child in her current pregnancy.

The effects of alcohol on an earlier child may be mild or

unrecognized. For women and girls who are pregnant or nursing,

no alcohol is the best practice for them and their babies.

An FASD lasts a lifetime.It cannot be cured,but it can be prevented.
Show your concern.
 

Encourage a pregnant woman or girl to see a medical provider to get

good prenatal care. Emphasize the importance of taking prenatal vitamins,

folic acid and only drugs or substances as prescribed or approved by the

health care provider.Ask whether she has a physician, access to a clinic, or

needs help to find someone to provide prenatal care.

You can provide pivotal guidance at prenatal visits or whenever you meet

with a pregnant woman, her family members, or her friends.

Concern about alcohol abuse should not stop with pregnant clients.

Talk with all women and girls of childbearing age about alcohol use

and, if needed, intervene to assist them in changing their behavior to help

prevent FASD.To help a woman or girl, use the“5­A’s”approach, which is

consistent with successful SBI methods:6

Assess: Ask her about alcohol use.

Advise: Advise her to take appropriate action—to stop drinking if she

is trying to become pregnant or if she is drinking and not using a

contraceptive.

Agree: Ask her to agree to take specific actions to change her

drinking behavior. For instance: “Can we agree that you will try to

avoid the people and situations usually associated with your

drinking?”

Assist: Assist her in taking the actions.

Arrange: Arrange for follow­up, monitor progress, and repeat the

intervention.

Your approach with women and girls of childbearing age who engage in

risky drinking or binge drinking may influence them to change their

behaviors and reduce the risk for an alcohol­exposed pregnancy and other

health problems in the future.

6

O’Connor, M.J., and Whaley, S.E. 2007. Brief intervention for alcohol use by pregnant women.American Journal of Public Health

97(2):252­258.
Speak up.

Experts estimate that each year at least 40,000 babies are

born with an FASD, costing the Nation up to $6 billion

annually in institutional and medical costs. 7

Advise your clients that the best time to stop drinking alcohol is when

they start to think about getting pregnant.You can also reassure women

and girls who are already pregnant that, if they stop drinking now,they

will reduce the potential for harm to the fetus.

Prevention is the only cure.

You may request companion pamphlets for mothers­to­be,family, and

friends through the SAMHSA Store.Available in English and Spanish,they

include:

How to have a healthy baby: Be an alcohol­free mother­to­be

Tipsfor Women:How to help your family member or friend

Tipsfor Men:How to help your family member or friend

To order publications, call 1­877­SAMHSA­7 (1­877­726­4727) or access the

Web site http://www.samhsa.store.gov.

If you want more information and training on FASD, visit the SAMHSA

FASD Center for Excellence Web site http://www.fascenter.samhsa.gov/.

7

Popova, S.; Stade, B.; Bekmuradov, D.; et al. 2011.What do we know about the economic impact of fetal alcohol spectrum

disorder? A systematic literature review.Alcohol and Alcoholism 46(4):490­497.

Printed 2004

Reissued 2015 

Help a patient or client

healthy

alcohol­free

mother­to­be.

baby.

have a

Help her

to be an