Adverse childhood experiences (ACEs) are preventable, potentially traumatic childhood (0–17 years of age) events including neglect, abuse, experiencing or witnessing violence in the home or community, or having a family member attempt or die by suicide (Merrick et al., 2019). Also included are aspects of a child’s environment that can undermine their sense of safety, stability, and bonding, such as living in a household where a parent is negatively affected by alcohol or other substance use or mental health condition, or when a child experiences instability because of separation from a parent or caregiver. ACEs often co-occur, and their accumulation is associated with a range of adverse behavioral, health, and social outcomes that can last into adulthood, including depression, lower education and earnings potential, chronic diseases, and alcohol and other substance use disorders (Merrick et al., 2019; Chung et al., 2010).

Alcohol use during pregnancy can cause adverse birth outcomes including miscarriage, stillbirth and preterm birth, and a range of lifelong behavioral, intellectual, and physical disabilities for the child (Dejong et al., 2019). The prevalence of alcohol use during pregnancy increased from 9.2 % in 2011 to 11.3 % in 2018 (Denny et al., 2020). Previous studies have found that ACEs are associated with higher odds of alcohol use during pregnancy, but had limited generalizability, not reflective of current alcohol use during pregnancy patterns, and focused on cumulative ACE scores (Chung et al., 2010; Frankenberger et al., 2015). Specifically, one study found that the total number of ACEs experienced was related to alcohol use during pregnancy in a dose-response manner; however, this study only assessed cumulative ACEs among a clinical sample of pregnant people that were low-income, young, and African American, and therefore had limited generalizability (Chung et al., 2010). Another study focused on data from a single U.S. state in 2010 and also found a dose-response relationship between number of ACEs and alcohol use during pregnancy; these results are specific to a single jurisdiction and might not reflect recent patterns in alcohol use during pregnancy, which has increased (Denny et al., 2020; Frankenberger et al., 2015). Using more recent, population-based data from multiple states that represent the entire state’s population to understand the role ACEs play in alcohol use during pregnancy can inform ways to mitigate the effects of ACEs. This study aimed to analyze data from 41 U.S. jurisdictions during 2019–2023 to 1) estimate the prevalence of alcohol use during pregnancy by ACEs and 2) examine associations between ACEs and alcohol use during pregnancy.

The overall prevalence of current alcohol use among pregnant persons was 12.2 %. Among those reporting frequent mental distress, prevalence of alcohol use during pregnancy was 31.2 %, compared with 9.3 % among those not reporting frequent mental distress (P < 0.001). The prevalence of alcohol use during pregnancy was 16.2 % among those reporting 4+ ACEs, 12.7 % among those reporting 1–3 ACEs, and 8.6 % among those reporting no ACEs (P = 0.002) (Table 1).

Pregnant persons who reported experiencing 4+ ACEs had increased prevalence of alcohol use during pregnancy compared to those who reported no ACEs (aPR = 1.8, 95 % CI = 1.1–2.9). People who reported experiencing emotional abuse (aPR = 1.9, 95 % CI = 1.3–2.7) and witnessing intimate partner violence (aPR = 1.6, 95 % CI = 1.1–2.4) had a higher prevalence of alcohol use during pregnancy compared to those who did not report experiencing those ACEs (Table 2).

Using data from 41 jurisdictions, this study showed that high ACE exposure was associated with increased prevalence of alcohol use during pregnancy, with these findings are consistent with previous studies exploring ACEs and alcohol use during pregnancy but was conducted on a larger scale across 41 U.S. jurisdictions from 2019 to 2023 and incorporated individual ACEs. Taken together, these results suggest clinical and population-based steps might be needed to mitigate the effects of ACEs (Chung et al., 2010; Dejong et al., 2019; Denny et al., 2020; Frankenberger et al., 2015).

The perinatal period is an opportunity when clinicians can help address adversity and trauma, including ACEs. The American College of Obstetricians and Gynecologists (ACOG) recommends universally screening for trauma and applying a trauma-informed care approach, even if a history of trauma is not disclosed; this approach is grounded in understanding and responding to the impact of trauma, incorporating this knowledge into care delivery, and creating opportunities for patients to rebuild a sense of control in their care (Caring for Patients Who Have Experienced Trauma, 2021). Components of a trauma-informed care approach include seeking permission before initiating physical contact with a patient, thoroughly explaining examinations, and allowing a patient to stop the examination if they want to, all of which can lessen anxiety and encourage active patient involvement in their own care (Caring for Patients Who Have Experienced Trauma, 2021). A trauma-informed care approach also includes referrals when trauma-specific services cannot be delivered in primary or perinatal care. Pairing trauma-informed care with alcohol screening and brief intervention provides a patient-centered approach that can facilitate linkage to services and support, such as substance use and mental health treatment, to address the holistic needs of the patient (CDC, 2020; Luong et al., 2023).

Population-based approaches can be implemented outside of health care systems to lessen immediate and long-term harms of ACEs, frequent mental distress, and substance use. Approaches such as public education campaigns that promote creation of safe, stable, nurturing relationships and environments for all children have been effective in preventing ACEs (Centers for Disease Control and Prevention, 2019b). Furthermore, services for persons who experience childhood adversity, including crisis intervention, housing support, and social support services, can reduce harms associated with ACEs (Centers for Disease Control and Prevention, 2019b).

Previous studies did not assess specific ACEs in relation to subsequent alcohol use during pregnancy; this study found that experiencing emotional abuse and witnessing intimate partner violence during childhood was associated with alcohol use during pregnancy. Previous studies have found associations between ACEs, psychological distress, and substance use (Gosdin et al., 2022; Strine et al., 2012). Persons exposed to childhood traumas such as physical or emotional abuse might be more likely to report earlier onset of depression and experience psychological distress, which in turn might increase use of alcohol (Strine et al., 2012). Universal screening for depression or anxiety is recommended by ACOG and the United States Preventive Services Task Force for all women during primary and perinatal care, which can increase access to mental and behavioral health services, if needed (Implementing Perinatal Mental Health Screening, 2024). Additionally, a family-centered treatment approach that incorporates evidence-based substance use disorder treatment with services such as childcare, mental health services, and medical services can address the intersections of substance use, mental health, and ACE exposure (Centers for Disease Control and Prevention, 2019b).

This study has strengths and limitations. This study was strengthened by the use of a large dataset representative of 41 U.S. jurisdictions, enhancing the generalizability of our findings compared to previous studies that rely on data from one jurisdiction or clinical center (Chung et al., 2010; Frankenberger et al., 2015). Additionally, this analysis not only operationalized between number of ACEs, but also the type of ACEs, finding specifically that emotional abuse and witnessing intimate partner violence were associated with higher prevalence of alcohol use compared to those who didn’t have those ACEs, providing a more comprehensive understanding of individual ACEs and allowing identification of emotional abuse and intimate partner violence as being associated with alcohol use during pregnancy. As for limitations, questions about ACEs and alcohol use during pregnancy might be subject to recall or social desirability bias. The COVID-19 pandemic might have influenced findings because of challenges with data collection or changes in alcohol use. Current alcohol use might not reflect alcohol use patterns throughout pregnancy. Lastly, results are only applicable to the jurisdictions from which data were available.

Higher ACE exposure, particularly exposure to emotional abuse and intimate partner violence as a child, were associated with alcohol use during pregnancy. Steps can be taken to mitigate the negative effects of ACEs and alcohol use during pregnancy that might result in adverse maternal and child health outcomes.