Appendix_J_Clinician's Guide

Drinking and

Reproductive

Health

A Fetal Alcohol
Spectrum Disorders
Prevention Tool Kit

A continuing education activity sponsored by the American College of Obstetricians and Gynecologists
Supported by the US Department of Health and Human Services, Centers for Disease Control and Prevention

Continuing Medical Education Information
Drinking and Reproductive Health: A Fetal Alcohol
Spectrum Disorders Prevention Tool Kit has been planned
and implemented in accordance with the Essential Areas
and Policies of the Accreditation Council for Continuing
Medical Education (ACCME) through the American
College of Obstetricians and Gynecologists (ACOG).
ACOG is accredited by the ACCME to provide
continuing medical education (CME) for physicians. ACOG
designates this educational activity for a maximum of 3
AMA PRA Category 1 CreditsTM. Each physician should
claim only those hours he or she actually spent in the
educational activity.

Acknowledgment
ACOG gratefully acknowledges the US Department of
Health and Human Services, Centers for Disease Control
and Prevention, for its support for this activity.

Sponsor
This CME activity is sponsored by ACOG.

Instructions for CME Credit
To earn CME credit, participants in this activity must read
the publication and complete and return the answer sheet
and evaluation form available at www.acog.org/ and on
the FASD Prevention Tool Kit CD.

Target Audience
This CME activity is intended for all health care providers
who care for reproductive-age women.

Learning Objectives
Upon completion of this CME activity, participants will be
able to:
•

Define, quantify, and recognize the significance
of risky drinking and the use of effective
contraception for women of reproductive age.

•

Identify a method (or methods) to effectively
screen for risky drinking in women of reproductive age.

•

Understand the use and content of brief
intervention to educate and counsel women
about risky drinking and fetal alcohol spectrum
disorders (FASD) prevention.

•

Identify methods to address patient concerns
about drinking and reproductive health.

•

Identify patient and family-oriented information
resources on FASD prevention.

Release and Expiration
Release date: October 2006; expiration date:
October 2008

Tool Kit Faculty
Chair
Robert J. Sokol, MD, FACOG
Director, C.S. Mott Center for Human Growth and Development
Wayne State University
Detroit, Michigan

Contributors and Reviewers
Centers for Disease Control and Prevention Advisors
Louise Floyd, DSN, RN
Elizabeth Parra Dang, MPH
Sherry Dyche Ceperich, PhD
Clinician Reviewers
Joseph Borzelleca, Jr., MD, FACOG, Richmond, Virginia
Mary J. O’Connor, PhD, ABPP, Los Angeles, California
Natalie E. Roche, MD, FACOG, Newark, New Jersey
Jacqueline Starer, MD, FACOG, ASAM, Brookline,
Massachusetts
Kristen L. Barry, PhD, Ann Arbor, Michigan

©2006 The American College of Obstetricians and Gynecologists



ACOG Division of Women’s Health Issues
Luella Klein, MD, Vice President
Janet Chapin, RN, MPH, Director
Jeanne Mahoney, Project Administrator

Drinking and

Reproductive Health
A Fetal Alcohol
Spectrum Disorders
Prevention Tool Kit
Prevention of fetal alcohol spectrum disorders (FASD)
begins during routine gynecologic care prior to
conception and continues through the postpartum
period. With information on screening, education, and
counseling, this publication will help women’s health
care clinicians prevent FASD when they encounter
risky drinking, regardless of pregnancy status.
In addition to this guide, the Tool Kit includes the
following:
Tools for Patients--information about drinking and
reproductive health
Tools for Clinicians--additional screening tools and
counseling tips
A pocket card illustrating standard-sized drinks

Table of Contents
Continuing Medical Education Information 2
Fetal Alcohol Spectrum Disorders

4

Screening and Intervention Guidelines

6

Frequently Asked Questions

8

A Blueprint for Putting Screening
and Intervention into Practice

9

Resources

10

References

11

US Surgeon General’s Advisory on
Alcohol Use in Pregnancy

12



Fetal Alcohol Spectrum Disorders
Fetal alcohol spectrum disorders (FASD) is an umbrella
term that describes the range of effects that can occur to
an individual whose mother drank during pregnancy.1
These effects may include physical, mental, behavioral,
and learning disabilities with lifelong implications. The
term FASD is not intended for use as a clinical diagnosis
but encompasses a spectrum of conditions that may occur as a result of prenatal alcohol exposure. Other terms
that describe effects of prenatal alcohol exposure include
alcohol-related birth defects and alcohol-related neurodevelopmental disorders.
Prevention of FASD begins during routine gynecologic care prior to conception and continues through
the postpartum period. Intervention includes screening
for alcohol consumption among all women of childbearing age and providing education and counseling when
risky drinking is encountered, regardless of pregnancy
status. Intervention may also include assessing effective
contraception practices in women not trying to become
pregnant who are drinking at risky levels.

Risk Factors, Prevalence
Maternal risk factors for an alcohol-exposed pregnancy
include
• smoking
• a history of inpatient treatment for drugs or
alcohol
• a history of inpatient mental health treatment

FETAL ALCOHOL SYNDROME (FAS)
Fetal alcohol syndrome (FAS) is the most severe disorder
resulting from prenatal alcohol use.1,3 In its 1996 report on
FAS, the Institute of Medicine concluded that FAS and other
conditions associated with prenatal alcohol exposures are
“completely preventable birth defects and neurodevelopmental
abnormalities.”4 The report stated that FAS is arguably the most
common nongenetic cause of mental retardation. Alcohol
affects the development of skeletal structures, organs, the
central nervous system, and overall growth.1 Specific characteristics associated with FAS include:

• central nervous system abnormalities, including at
least one structural, neurologic, or functional
abnormality
• growth deficits

• facial dysmorphia, including a smooth philtrum, thin
vermillion border, and short palpebral fissures

Women at high risk for giving birth to a child with FAS
include those who drink heavily and are either pregnant or at
risk of becoming pregnant, and particularly those who have
already had a child with FAS.1,4,5
The reported incidence of FAS varies depending on the
population being studied and the ability and willingness of
providers to recognize and report it. In the United States, the
prevalence of FAS ranges from 0.5 to 2 cases per 1,000
births; rates are higher among subpopulations, such as some
Native Americans, African Americans, and selected minority
groups.1,2,6

• having multiple sex partners
• recent physical abuse2
FASD may be found in all ethnic and social groups.

When to Use This Tool Kit
This publication presents an intervention kit developed
to help women’s health care clinicians prevent FASD.
Interventions are designed to:

• identify risky alcohol use before and during
pregnancy and

• promote the use of effective contraception among
women who engage in risky drinking while
working toward alcohol reduction goals

This Tool Kit provides the clinician with strategies
to reduce alcohol exposure to the developing fetus. It
consists of a simple screening tool and intervention for
pregnant women that can be incorporated into routine
care. The method is based on proven, effective techniques
and can be used by many levels of providers in office,
clinic, or community settings.



Fetal Alcohol Syndrome:
The Tip of the Iceberg
Considering the effects of alcohol use in pregnancy, FAS is the
tip of the iceberg. For every child born with FAS, many more
children are born with neurobehavioral deficits caused by alcohol exposure but without the physical characteristics of FAS.2

Women may be at risk for alcohol-related problems if their
consumption exceeds 3 drinks per occasion or more than 7
drinks per week.7 Any amount of drinking is risky for women
who are pregnant or trying to become pregnant.2

Drinking Prevalence and Patterns
Government survey data of substance abuse from 2002
and 2003 indicate that 9.8% of pregnant women aged
15 to 44 reported drinking alcohol, and 4.1% reported
binge drinking, defined as 5 or more drinks consumed on
one occasion (Figure).8 The definition of binge drinking as
5 or more drinks was developed for the general population and not specifically for women. In 2005, the NIAAA
defined binge drinking for women as more than 3 drinks
per occasion.7
A Centers for Disease Control and Prevention (CDC)
study found that binge drinking episodes per person per
year increased between 1995 and 2001 by 35% and
that 47% of binge drinking episodes occurred among
otherwise moderate drinkers.9 Binge drinking in pregnant
women is of particular concern because spikes in blood
alcohol levels may result in more severe teratogenic
effects overall than those associated with daily drinking at
lower levels of consumption.1

Rationale for Intervention
The impact of alcohol begins during early organogenesis,
after implantation but before many women know they are
pregnant. Alcohol readily crosses the placenta and may
cause neurobehavioral effects early during pregnancy.10
It is therefore classified as a neurobehavioral teratogen.
It appears that even moderate alcohol consumption
during pregnancy may alter psychomotor development,
contribute to cognitive deficits, and produce emotional
and behavioral problems in children, although patient
denial and underreporting make it difficult to quantify
these effects.11–13 There is evidence of varying susceptibility to alcohol’s effect on the developing baby. While
alcohol consumption may have negative consequences
for any pregnant woman, the effects of alcohol may be
more potent in mothers who are older, in poor health, or
who also smoke or use drugs.10
Because many women have unintended pregnancies and may not be aware they are pregnant for several
weeks, it is important to intervene with all women of
childbearing age to prevent a potential alcohol-exposed
pregnancy.

No safe level of alcohol consumption during
pregnancy has been identified, and no period
during pregnancy appears to be safe for alcohol
consumption.2

Screening and Intervention
At minimum, periodic screening for risky alcohol use
should take place on admission to care, during periodic
or annual gynecologic visits, and at the first prenatal visit.
Several screening instruments are available to identify
alcohol use in patients.14,15 All pregnant women and
those trying to become pregnant should be counseled to
avoid alcohol consumption.4,6,10 In addition, any woman of
childbearing age who drinks at levels that put her at risk
should be counseled to use effective contraception and
be provided with specific strategies to reduce her alcohol
consumption. Intervention should be directed toward
women who are at risk as well as toward their partners,
family members, and close friends.4 As of January 2007,
new coding is available through Medicaid for physician
reimbursement for alcohol screening and brief intervention.

Brief Interventions Are Effective
There is strong evidence that brief behavioral counseling interventions for risky drinking by both pregnant and
nonpregnant reproductive-age women reduce the risk of
alcohol-exposed pregnancy. In one multicenter project,
nearly 70% of women who were drinking at risky levels
and not using effective contraception reduced their risk
of an alcohol-exposed pregnancy 6 months after a brief
intervention because they stopped or reduced their
drinking below risky levels, or they started using effective
contraception.15 For women who are already pregnant,
randomized studies reported significant reductions in
alcohol use and improved newborn outcomes after
intervention.14,16
Figure. Past month alcohol use in pregnant women by age, 2002
and 2003.8 Pregnant women ages 15 to 25 years old reported
slightly higher rates of all alcohol consumption than women older
than 25 years.

Alcohol use among pregnant women (%)

How much is too much?

12
10

Women aged 15 to 25 years

10.9

Women aged 26 to 44 years
8.9

8
6

5

4

3.3

2
0

0.7
Any alcohol use

Binge drinking

0.6

Heavy alcohol use*

*Heavy alcohol use was defined as 5 or more drinks on the same
occasion on each of 5 or more days in the past 30 days; heavy alcohol
users were also binge drinkers.



Screening and Intervention Guidelines

These three simple steps have been proven effective in identifying women who drink at risky levels and engage them
in changing behavior to reduce their risk for an alcohol-exposed pregnancy.

Step 1:
Ask About Alcohol Use

Step 2:
Brief Intervention

Ask:

Brief, motivation-enhancing interventions are associated with
sustained reduction in alcohol consumption by women of childbearing age.17 ,18 The FRAMES model has successfully helped
clinicians deliver brief interventions.20,21

“I have a few routine questions for you about when you
use alcohol. Have you ever had a drink containing
alcohol?”
If the patient answers yes, continue using a validated
screening tool such as the T-ACE.19 The most valid
disclosure may result if the screening questions are
incorporated into a form completed by the patient.

F Feedback

Compare the patient’s level of drinking with drinking patterns
that are not risky. She may not be aware that what she
considers normal is actually risky.

T Tolerance:

R Responsibility

A Advice

How many drinks does it take to make you feel high?
(>2 drinks = 2 points)

A Annoyed:

Have people annoyed you by criticizing your drinking?
(yes = 1 point)

E Eye-opener:

Have you ever had a drink first thing in the morning to
steady your nerves or get rid of a hangover?
(yes = 1 point)

Give direct advice (not insistence) to change her drinking
behavior.

M Menu

C Cut down:
Have you ever felt you ought to cut down on your drinking?
(yes = 1 point)

Stress that it is her responsibility to make a change.

Identify risky drinking situations and offer options for coping.

E Empathy
Use a style of interaction that is understanding and involved.

S Self-efficacy

Elicit and reinforce self-motivating statements such as, “I
am confident that I can stop drinking.” Encourage the patient
to develop strategies, implement them, and commit to change.

It takes about 1 minute to ask the T-ACE questions.
Determine the quantity and frequency of drinking.
Educate the patient about what constitutes a
standard-sized drink by showing her the “Standard
Drink Equivalents” card in the Tool Kit.
Ask:
“On average, how many standard-sized drinks containing
alcohol do you have in a week?”
“When you drink, what is the maximum number of
standard-sized drinks you have at one time?”
Proceed to Step 2 (Brief Intervention) when:



•

Her T-ACE score is 2 or more points

•

The patient is not pregnant or not trying to become
pregnant and she is having an average of more than
7 standard-sized drinks per week or more than 3
standard-sized drinks on any one occasion

•

The patient is pregnant or trying to become
pregnant and drinking

Ensuring Effective Contraception
A woman who drinks alcohol at risky levels may not always
follow prescribed procedures for effective contraception.
Review contraception use with her to ensure that she has full
contraceptive coverage every time she has sexual intercourse.
This might include providing secondary, back-up, or emergency contraception methods. For example, along with oral
contraceptives, advise her to use condoms, which have the
added benefit of reducing sexually transmitted diseases.

Examples of interventions using the FRAMES model:
For patients who are pregnant:
“You’ve already done many good things to help your baby be
healthy. You mentioned that you’re having
drinks. There is
no known safe amount of drinking when you’re pregnant. Drinking during pregnancy could cause complications for you and your
baby. I’d certainly suggest that you stop drinking now.”
Be prepared to respond to a patient who is concerned that she
has already hurt her baby with cautious reassurance. If her
drinking appears to have been very heavy, options counseling
may be advised.
After giving your advice, ask for a response to make sure the
patient understands the need to take action:
“What do you think about what I’ve just said? How do you feel
about working with me to quit drinking?”
Establish a contract to quit drinking.
For patients who are not pregnant and are not trying to
become pregnant:
“Your drinking is in the range that we call ‘risky drinking’
because it can cause health risks for you. These risks include
injury, sexually transmitted diseases, unplanned pregnancy,
and potentially an alcohol-exposed pregnancy. If you become
pregnant, your baby could be seriously affected. It is important to
reduce your drinking to no more than 7 drinks per week and no
more than 3 drinks on any one occasion. It is also important to
use effective birth control every time you have sex.”

Step 3:
Follow-up for Women Who Engage
In Risky Drinking
At follow-up visits, monitor progress on alcohol goals and
use of effective contraception (if relevant).
•

Patient meets her goals: Congratulate her and
reinforce her behavior change.

•

Patient doesn’t meet her goals: Restate your
advice to quit or cut back, review her plan, and
work with her to modify, if necessary. Encourage
her and offer additional support.
• Patient continues risky drinking: If she is pregnant or trying to become pregnant, encourage
her to abstain, discuss treatment options, and
follow-up with message reinforcement. If the
patient is not pregnant or not trying to become
pregnant, encourage her to cut back on drinking,
especially if she is not using consistent, effective
contraception. Discuss treatment options as applicable.
• Patient is referred for additional treatment:
Ensure that she followed up, and ask for her
treatment status.
If a patient was drinking when she became pregnant or
drank during her pregnancy, reassure her that the things
she is doing now to quit or cut back can increase the
likelihood that her baby will be healthy.

Ask for a response to your advice to make sure the patient
understands the need to take action:
“What do you think about what I’ve just said? How do you feel
about reducing your drinking below risky levels? What about
using effective birth control?”
If the patient agrees, consider establishing goals and a change
plan with her to reinforce behavior changes. (See “MY PLAN for
Alcohol” and “MY PLAN for Birth Control,” Tools for Clinicians in
the Tool Kit.)
Candidates for referral
Refer the following patients to behavioral health specialists for
additional evaluation:
•

Women who have attempted to quit drinking but have
been unsuccessful

•

Women who continue to drink despite negative health
and social consequences

•

Women whom you suspect of having alcohol abuse or
dependence problems

It can be helpful to assist the patient with making an appointment with a behavioral specialist while she is in your office.



Frequently Asked Questions
Q: What do I say to a woman who is practicing risky
drinking behavior but has no intention of getting
pregnant?
A: Tell her that research has established that women
experience more medical consequences from alcohol
over a shorter period of drinking compared with men
who drink at the same level. Reinforce that having more
than 7 drinks per week or more than 3 drinks on any
one occasion is considered risky drinking. Reiterate the
potential for injury, sexually transmitted diseases, unwanted pregnancy, and other health risks. Also reiterate
that nearly half of all pregnancies in the United States are
unintended; when a woman isn’t trying to become pregnant, she may unknowingly damage her unborn baby by
drinking even before she finds out that she is pregnant.
Encourage her to use effective birth control.
Q: What do I say to my patients who drank alcohol
throughout other pregnancies and had babies without
symptoms of FASD?
A: Every pregnancy is different. Drinking alcohol may
hurt one baby more than another. Tell her she could have
one child who is born healthy and another child who is
born with problems. Also tell her that as she gets older,
her drinking is more likely to hurt her baby.
Q: My patient is dependent on alcohol but also has
other children at home. Is there alcohol treatment
available for pregnant and parenting women?
A: Most states have women-specific and pregnancyspecific treatment programs for alcohol and drug abuse.
These programs may offer child care and parenting support. See Resources for contact information.
Q: One of my patients said that antioxidants cancel
out the harmful effects of alcohol on the fetus. What
does the literature say about this?
A: There is no evidence that antioxidants can mitigate
the effects of alcohol on pregnancy. Alcohol has many
mechanisms by which it exerts a negative effect on
pregnancy.
Q: I see many women who had a few drinks in early
pregnancy and are now very worried that they have
seriously damaged their babies. What should I tell
them?
A: Although there is no known threshold of safety for
alcohol use during pregnancy, there have been no known
cases of damage to the fetus from non-risky drinking in
early pregnancy. Stopping drinking at any point in her
pregnancy is best for her and her baby. From this point
of her pregnancy on, she should abstain from drinking.
Consider talking to the pediatrician about the patient’s
concerns after the child is born. In some instances, it may
be reassuring to the patient to have her child evaluated
by a developmental psychologist.


Q: Occasionally I see a patient who appears to have
alcohol dependence. What should I do?
A: Acknowledge that reducing or quitting drinking is
hard, and tell her that many people find the best way to
quit is with help. Describe the kinds of help she can get,
including care from treatment specialists, medication (eg,
naltrexone for nonpregnant women), and support from
mutual help groups (see Resources). Involve the patient
in making referral decisions and, if possible, help her
schedule a referral appointment while she is in the office.
Q: How do I avoid affecting my patients’ insurability
when we discuss alcohol use?
A: Obstetrician/gynecologists are not trained to offer a
formal diagnosis of substance abuse and therefore should
not code for it in communication with insurers.
Q: From a risk-management perspective, what are
the strategies that decrease my risk if my patient’s
baby is eventually diagnosed with FASD?
A: Include documentation in the patient’s chart that you
have performed risk screening and, when applicable,
brief intervention and follow-up.
Q: How do I respond when the patient tells me that
other clinicians have not determined that her drinking is a problem?
A: Tell the patient that you specialize in caring for women
and babies. Other physicians specialize in other kinds
of care and might not have asked the same kinds of
questions or discussed plans for pregnancy with her.
Also, some physicians may not be aware of the effects of
alcohol on women and their children. Tell her that you’re
particularly concerned because drinking that wouldn’t
be risky for nonpregnant women can cause complications for pregnant women and their babies. Recognition
that alcohol affects men and women differently is recent;
women are at risk drinking less alcohol than previously
thought.
Q: How serious are the effects of drinking on a fetus?
A: Prenatal exposure to alcohol is one of the leading preventable causes of birth defects. Heavy exposure can lead
to spontaneous abortion (miscarriage), stillbirth, anatomic
congenital anomalies, and abnormal neurobehavioral
development, including lowered IQ, mental retardation,
and behavioral problems.
Q: How do I respond to questions concerning reports
to authorities on alcohol use, particularly for pregnant women?
A: Seeking obstetric-gynecologic care should not expose
a woman to criminal or civil penalties or the loss of her
children. As with other confidential medical information, a
patient’s history of alcohol use should not be made available to police or government agencies unless specifically
required by law.22

A Blueprint for Putting Screening
and Intervention into Practice
For most busy obstetric and gynecologic practices, time
is at a premium. Finding time to use these screening and
brief interventions will be challenging. Successful strategies used by busy clinicians to incorporate these steps
are included here to help you identify and assist women
at risk:
•

Review this Tool Kit with other office personnel.
Discuss areas of resistance. Decide who will do
each step and where that will be done.

•

Incorporate the screening tools on a health
questionnaire completed by the patient in a
private area prior to seeing the clinician. Use this
questionnaire for other health questions, such as
smoking, drug use, abuse, physical activity. (See
the ACOG website for more information about
psychosocial screening.)

Background Information for Nonpregnant
Women
Tell your patient:
“Here is some information that has been learned through
research; I’d like to share it with you”:
•

Alcohol is a drug that can have harmful effects;
the more alcohol someone drinks, the stronger
the effects.

•

If a woman has more than 7 drinks a week
or more than 3 drinks on a single day, she is
engaging in risky drinking.

•

Risky drinking increases a woman’s chances of
developing alcohol-related illnesses, suffering
injuries, having an unplanned pregnancy, and
contracting a sexually transmitted disease.

•

If the patient is unable to read the questionnaire,
ask an office staff member to assist her.

•

There is no known safe level of drinking for
pregnant women.

•

The brief intervention, referrals, and follow-up
can be initiated by the clinician and completed by
a nurse, social worker, or other professional staff.

•

When a woman engages in risky drinking, is
sexually active, and doesn’t use effective birth
control, she is at greater risk for:

•

Identify local resources for further evaluation and
treatment of patients prior to initiating screening and intervention. (See Resources for more
information.)

• Becoming pregnant
• Having a baby with birth defects or brain
damage caused by heavy drinking; this
includes fetal alcohol syndrome
•

About half of all pregnancies occur when women
are not trying to become pregnant; many do not
realize they are pregnant until the second or
third month.

•

Many safe birth control methods are available
that can keep you from getting pregnant if you
use them each time you have vaginal intercourse.

Ask:
“What do you think about this?”

Develop a Change Plan
A patient who engages in risky drinking can use a
change plan to help her reach her goals. See sample
change plans in the handouts section of this Tool Kit.



Resources
Treatment and Referral Locator
Substance Abuse & Mental Health Services Administration (SAMHSA), Substance Abuse Treatment Facility
Locator: Available online at: http://dasis3.samhsa.gov. This site lists private and public facilities that are licensed,
certified, or otherwise approved for inclusion by state substance abuse agencies. Facilities for specific populations,
such as Spanish-speaking pregnant women, can be located through SAMHSA. Referral help lines operated by
SAMHSA’s Center for Substance Abuse Treatment include the following:
• 1-800-662-HELP (4357)
• 1-800-662-9832 (Español)
• 1-800-228-0427 (TDD)
Every state has a substance abuse agency that is usually operated by the State Department of Health. Contact
information for state substance abuse agencies is available online at:
http://findtreatment.samhsa.gov/ufds/abusedirectors.

Federal Agencies
National Institute on Alcohol Abuse and Alcoholism (NIAAA): Available online at: http://www.niaaa.nih.gov.
The NIAAA provides material for patients and providers covering a wide range of alcohol-related topics. Patient
information includes pamphlets, brochures, and posters written in an easy-to-read format. Materials for patients
are available in English and Spanish and are free except where otherwise noted. Provider materials are available
for physicians, social workers, and other health care professionals.
Centers for Disease Control and Prevention (CDC), Fetal Alcohol Syndrome (FAS)
Available online at: http://www.cdc.gov/ncbddd/fas. This site includes links to the FAS Guidelines for Referral
and Diagnosis, frequently asked questions, fact sheets, and statistics about alcohol consumption among pregnant
women. Posters, patient brochures, and other materials are available free of charge. Information is provided about
collaboration between the American College of Obstetricians and Gynecologists (ACOG) and the CDC’s FAS Prevention Team to develop educational materials for health care providers.
SAMHSA, Fetal Alcohol Spectrum Disorders (FASD) Center for Excellence: Available at:
http://fasdcenter.samhsa.gov. The FASD Center for Excellence provides educational materials including fact sheets,
brochures, posters, and many types of publications and educational materials regarding FASD.

National Organizations
National Organization on FAS (NOFAS): Available online at http://www.nofas.org. This site offers summaries
of FASD research and patient screening tools for health care professionals. Additional information is available
for educators, expectant mothers, persons with FASD, and patient advocates. The site also has a national and
state resource directory that provides the location of resources by state, including alcohol treatment facilities, FAS
diagnostic specialists, support groups, and more.

Publications
Chang G. Alcohol-screening instruments for pregnant women. Alcohol Res Health 2001; 25(3):204–209.
Available at: http://pubs.niaaa.nih.gov/publications/arh25-3/204-209.htm. This article provides an overview of
commonly used screening tools for alcohol use in pregnant women.
National Institute on Alcohol Abuse and Alcoholism. A Pocket Guide for Alcohol Screening and Brief Intervention.
2005. Rockville, MD: National Institutes of Health; 2005. Available at:
http://pubs.niaaa.nih.gov/publications/Practitioner/PocketGuide/pocket_guide.htm.
National Institute on Alcohol Abuse and Alcoholism and Office of Research on Minority Health. Identification of
At-Risk Drinking and Intervention with Women of Childbearing Age: A guide for primary-care providers.
Rockville, MD: National Institutes of Health; 1999. NIH publication 99-4368. Available at:
http://www.health.state.mn.us/fas/at-risk-drinking/at-risk.html.

10

References
1.

Bertrand J, Floyd RL, Weber MK, et al. Fetal Alcohol Syndrome:
Guidelines for Referral and Diagnosis. Atlanta, GA; 2004. Available at: http://www.cdc.gov/ncbddd/fas/documents/FAS_guidelines_accessible.pdf. Accessed on December 20, 2005.

11. Larroque B, Kaminski M, Dehaene P, Subtil D, Delfosse MJ,
Querleu D. Moderate prenatal alcohol exposure and psychomotor development at preschool age. Am J Public Health
1995;85:1654–1661.

2.

US Surgeon General Releases Advisory on Alcohol Use in
Pregnancy. News release, February 21, 2005. US Department
of Health & Human Services. Available at: http://www.hhs.
gov/surgeongeneral/pressreleases/sg02222005.html. Accessed
on January 3, 2006.

12. Sood B, Delaney-Black V, Covington C, et al. Prenatal alcohol
exposure and childhood behavior at age 6 to 7 years: I. Doseresponse effect. Pediatrics 2001;108:1–9.

3.

March of Dimes. Drinking Alcohol During Pregnancy. Available at:
http://www.marchofdimes.com/professionals/14332_1170.asp.
Accessed on March 6, 2006.

4.

Institute of Medicine. Fetal Alcohol Syndrome: Diagnosis,
Epidemiology, Prevention, and Treatment (1996). Available at:
http://www.come-over.to/FAS/IOMsummary.htm. Accessed on
December 30, 2005.

5.

Abel EL. Fetal alcohol syndrome in families. Neurotoxicol Teratol
1988;10:1–2.

6.

American Academy of Pediatrics. Committee on Substance
Abuse and Committee on Children with Disabilities. Fetal alcohol
syndrome and alcohol-related neurodevelopmental disorders.
Pediatrics 2000;106(2 Pt 1):358–361.

7.

National Institute on Alcohol Abuse and Alcoholism (NIAAA).
A Pocket Guide for Alcohol Screening and Brief Intervention.
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US Surgeon General’s Advisory on Alcohol Use in Pregnancy
• Alcohol consumed during pregnancy increases the risk of alcohol-related birth defects,
including growth deficiencies, facial abnormalities, central nervous system impairment,
behavioral disorders, and impaired intellectual development.
• No amount of alcohol consumption can be considered safe during pregnancy.
• Alcohol can damage a fetus at any stage of pregnancy. Damage can occur in the earliest
weeks of pregnancy, even before a woman knows that she is pregnant.
• The cognitive deficits and behavioral problems resulting from prenatal alcohol exposure
are lifelong.
• Alcohol-related birth defects are completely preventable.
For these reasons:
• A pregnant woman should not drink alcohol during pregnancy.
• A pregnant woman who has already consumed alcohol during her pregnancy should stop
in order to minimize further risk.
• A woman who is considering becoming pregnant should abstain from alcohol.
• Recognizing that nearly half of all births in the United States are unplanned, women of
childbearing age should consult their physician and take steps to reduce the possibility of
prenatal alcohol exposure.
• Health professionals should inquire routinely about alcohol consumption by women of
childbearing age, inform them of the risks of alcohol consumption during pregnancy, and
advise them not to drink alcoholic beverages during pregnancy.
Source: http://www.hhs.gov/surgeongeneral/pressreleases/sg02222005.html

Print copies and a CD version of this guide can be requested through the American College of Obstetricians and
Gynecologists by FAXing request to 202-484-3917 or writing ACOG, Division of Women’s Health Issues,
PO Box 96920, Washington, DC
Drinking and Reproductive Health: A Fetal Alcohol Spectrum Disorders Prevention Tool Kit is available both in print
and as a PDF. Print copies and a CD version of the PDF can be requested through the American College of
Obstetricians and Gynecologists (ACOG). The PDF is also available on the ACOG website at: http://www.acog.org/.
Other resource materials mentioned in the Tool Kit are available on the CD and on the ACOG website.
Clinicians who wish to obtain CME credit must print the evaluation form from the CD or download it from the ACOG
website (www.acog.org/). Completed evaluation forms must be returned to ACOG to obtain credit. Instructions are
included on the CME evaluation form.
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