Prenatal alcohol exposure is a leading preventable cause of birth defects and neurodevelopmental disorders in the United States (US). Fetal alcohol spectrum disorders (FASD) is a term used to describe a range of behavioral, intellectual, and physical problems that may appear at any time during childhood and last a lifetime.¹ Due to the high rates of alcohol use and unintended pregnancies common in the US, the preconception period provides a clinical opportunity to educate individuals who may become pregnant to reduce the risk of alcohol-exposed pregnancies (AEPs).² Evidence suggests that early intervention approaches, such as alcohol screening and brief intervention (SBI), have the potential to reduce the harm from alcohol on maternal and infant health.³

According to its Chronic Disease Indicators, the Centers for Disease Control and Prevention (CDC) estimates that approximately 45% of all pregnancies in the US are unintended.⁴ An unintended pregnancy is defined as one that is either unwanted, that is, the pregnancy occurred when no children or no more children were desired; or the pregnancy was mistimed. Most unintended pregnancies result from not using contraception or from not using it consistently or correctly.⁴ Further, data from CDC’s Behavioral Risk Factor Surveillance System indicate that approximately half of adult women in the US report drinking alcohol in the past 30 days and 18% of those 18–44 years of age binge drink, consuming four or more drinks per occasion.⁵ During 2018–2020, 13.5% of pregnant adults reported current drinking, while 5.2% reported binge drinking.⁶

Alcohol SBI is an evidence-based clinical preventive service to identify and treat patients who are drinking at levels that put them at risk for short-term or long-term harms.^7–10 Alcohol SBI involves the use of 1) validated screening tools to classify patients’ risk levels, followed by 2) a short conversation with patients who are drinking too much and are at ‘moderate- or high-risk’ for harm. These BIs are designed to motivate patients to reduce their drinking levels or to accept a referral to specialty care as needed.⁹ A primary goal of this current initiative was to educate individuals at risk of an AEP through the implementation of alcohol SBI services in healthcare systems.

Although a number of reliable and valid alcohol screening tools exist, the World Health Organization’s (WHO’s) Alcohol Use Disorders Identification Test or AUDIT has been the most widely tested for screening in primary health care settings.^11–14 The AUDIT screens for the full spectrum of alcohol misuse and provides an assessment of lower-, moderate- or high-risk use. Based on the AUDIT-linked alcohol SBI protocol, patients who screen at moderate- or high-risk levels should receive a BI while those who screen at lower-risk levels do not.¹¹ Methods for identifying an individual’s risk status, based solely on a positive AUDIT (or other screen) score, will fail to identify patients drinking at low levels and who may be using less effective contraception. Consequently, the provider may miss an opportunity for an AEP prevention-focused educational intervention.¹⁵

Over 30 years of implementation and effectiveness research has shown that BIs, when implemented and delivered with fidelity, can reduce the amount of alcohol consumed and associated problems in those who are drinking too much^7–9; however, a focus on early intervention for multiple behavioral risk factors should be addressed to improve the quality of health care.^16–19 There have been fewer trials regarding implementation and effectiveness of interventions to reduce the risk of AEPs in individuals who may become pregnant. In a recent systematic review, Reid et al. described the results of 19 studies to evaluate preconception interventions to change alcohol use and/or contraceptive behavior, many of which were based on the seminal work of Floyd and colleagues.^2,20 Although the interventions reviewed were more intensive than a typical BI session, 4 face-to-face single-session interventions were effective in reducing the potential for AEPs.^21–24 Results of the overall systematic review indicated that many of the 19 interventions reduced AEP risk during the preconception period by preventing unplanned pregnancy and that changes in AEP risk were driven primarily by changes in contraception behavior; although, some approaches documented changes in both alcohol and contraception behavior.²

The background for this investigation was a cooperative agreement, funded by the Centers for Disease Control and Prevention across healthcare systems and academic institutions, to implement alcohol screening and brief intervention services.²⁵ The aim of this cross-sectional study was to identify the potential gap in alcohol SBI service delivery, by examining administrative data from two large reproductive health care systems: Planned Parenthood of Southern New England (PPSNE) and Planned Parenthood Great Northwest, Hawai’i, Alaska, Indiana, Kentucky (PPGNHAIK) to explore the prevalence of individuals who reported alcohol use that was categorized as ‘lower-risk’ on the USAUDIT screening tool, were using a “less effective” method of pregnancy prevention, and did not receive an alcohol-focused BI.

In the context of traditional alcohol SBI services, these patients would not be flagged to receive a BI because they did not meet the threshold for moderate- or high-risk use; however, they may be at risk of an AEP due to their method of pregnancy prevention. Opportunities for integrating electronic health record (EHR) flags to consider pregnancy prevention methods in conjunction with lower-risk drinking cutoff scores on standardized screening tools are discussed. Opportunities for providing AEP prevention-focused BIs are also considered.

Despite the significant differences in sample characteristics across the two health systems, between sample outcomes related to SBI delivery did not vary significantly, and for this reason the sample data were combined for the analyses. Figure 1 shows the combined samples of the 11567 screened patients. Of those, 7638 (66%) reported some alcohol use, but screened at a lower-risk level and thus would not have been flagged to receive an alcohol-focused BI based on their USAUDIT Risk Score. Of those reporting lower-risk use, 6439 (84.3%) did not receive a BI, consistent with the standard alcohol SBI protocol since they did not screen positive for at-risk alcohol use. Of those who were lower-risk drinkers and did not receive a BI, 1477 (22.9%) were using less effective pregnancy prevention and were therefore at risk of an AEP. Among the lower-risk alcohol group, there were no significant differences in receiving a BI based on effectiveness of pregnancy prevention for PPSNE (χ²_{(1, 3653)}=3.45, p=.06) or PPGNHAIK (χ²_{(1, 3985)}=1.31, p=.25), indicating providers were equally likely to provide a BI to patients using effective pregnancy prevention as those patients using less effective pregnancy prevention.

Of the total screened sample, 1676 (14.5%) would have been flagged for a BI based on their Alcohol Risk Score (Figure 1). The majority of patients screening positive and flagged for at-risk alcohol use (moderate- or high-risk) received a BI, 1162 (69.3%) while 514 (30.7%) did not receive a BI. Of those missed, 118 (23.0%) were using less effective pregnancy prevention and were therefore at risk of an AEP. Like the lower-risk alcohol group, in this at-risk alcohol use group, there were no significant differences in receiving a BI based on effectiveness of pregnancy prevention for PPSNE (χ²_{(1, 1038)}=2.42, p=.12) or PPGNHAIK (χ²_{(1, 638)}=2.64, p=.10). While the likelihood of receiving a BI did not differ based on pregnancy prevention method, overall, BIs were delivered more often to patients who screened positive for at-risk alcohol use than those reporting lower-risk alcohol use. In summary, the number of individuals at risk of an AEP who did not receive an alcohol BI were 1595 (13.8%) of the total number of patients screened for at-risk alcohol use.

The primary focus of this study was to identify the potential gap in alcohol SBI service delivery by examining the prevalence of individuals who reported alcohol use that was categorized as ‘lower-risk’ on the USAUDIT screening tool, were using a less effective method of pregnancy prevention, and did not receive an alcohol-focused BI. Full integration of a preventive practice that included universal administration of a valid, standardized screening tool, automated scoring and EHR-based provider alerts when patients screened positive, still missed an opportunity to provide an alcohol-related intervention to approximately 14% of individuals who reported consuming some alcohol and reported using a less reliable form of pregnancy prevention, a combination of behaviors that increased their risk for an AEP.

The continued focus in health care on screening and intervening on singular behavioral risk factors has been reported as a substantial area for improving the quality of care.^16–19,29 Like many health conditions that involve integrating behavioral and medical care,³⁰ preventing FASDs involves addressing not only alcohol use, but also identifying and addressing concurrent behaviors that contribute to pregnancy such as contraception use.³¹ This finding underscores the insufficiency of intervening on alcohol risk alone, without considering additional risk factors for AEP, and a need for interventions, tools and systems that are sufficiently flexible to assess multiple behaviors simultaneously.¹⁶

An EHR approach that uses patient-specific data to prioritize and tailor interventions is recommended given the potential of EHRs to not only document relevant demographic, physiological, health risk, and behavioral data, but to also combine data to guide care.^32–35 While some progress has been made in using the medical information in the EHR to optimize medication prescribing for patients with chronic conditions (e.g., diabetes, cancer), the EHR’s usefulness in combining information to guide brief interventions is an unexplored opportunity.