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1ALCOHOL CONSUMPTION OF PREGNANT WOMEN

Alcohol Consumption of Pregnant WomenHannah JohnsonClemson University

Health 240 sec-001: Determinants of HealthSpring 2014

Health Behavior

The consumption of alcohol during pregnancy has been ill advised by the Surgeon General since 1981 (Alcohol Policies Project), yet there are a large percentage of women who still consume alcohol during pregnancy. Many women are under the impression that alcohol is safe after the first three months of pregnancy; however, there is no known safe amount of alcohol that can be consumed during pregnancy (Albersten, Anderson, Olsen & Gronbaek, 2004). Warnings against alcohol consumption are in place because of the risk of termination of the fetus and ill effects that can occur to the fetus that can last throughout the childs life. Alcohol consumption may encompass having beer, wine, liquor, or wine coolers and is regarded as unsafe regardless of the frequency or amount consumed (Centers for Disease Control and Prevention, 2014). Women may also participate in binge drinking, which is defined as having 5 or more drinks on a single occasion (Chen, Rosner, Hankinson, Colditz & Willet, 2011). This behavior of drinking alcohol while pregnant is affected by both the personal cognition of the woman, by her environment, and by the cognitions of those in her environment. It is behavior whose alteration could provide financial benefits to the healthcare and school systems, as well as provide other societal benefits. StatisticsDrinking habits among women are typically collected by use of surveys. One survey, performed by the CDC through the years of 2006 2010 showed that 1 in 13 women, or 7.6%, of pregnant women had drank within the past 30 days of being surveyed. This number can be compared to the number of non-pregnant women who drank within 30 days of being surveyed which amounts to 51.5%. Of the pregnant women who partook in drinking, 14.3% were between the ages of 35 and 44 years of age, 8.3% where white, and 10% were college graduates. The percentage of women who reported binge drinking while pregnant amounted to 1.4% and of that percentage of women, most women binge drank 3 times and consumed around 6 drinks on each occasion (Marchetta et al., 2012). In a more recent survey, performed by Substance Abuse and Mental Health Services Administration (SAMHSA), 18% of pregnant women reported drinking in their first trimester. This survey, the National Survey on Drug Use and Health (NSDUH) was conducted between 2011 and 2013 revealing an increase in the percentage of women partaking in drinking during pregnancy from 2006-2010. This study also showed that 6% of pregnant women had binge drank during their first trimester. The percentage of pregnant women who drank did decrease as their pregnancies progressed with 4.2% in the second trimester and 3.7% in the third trimester reporting drinking (Substance Abuse and Mental Health Services Administration, 2013). Health OutcomesWomen who consume alcohol during pregnancy put both themselves and their future children at risk for health problems. The fetus, in particular, is at risk for problems that range in severity. It has been shown by the American Academy of Child and Adolescent Psychology that alcohol is the number one cause of birth defects (American Academy of Child and Adolescent Psychiatry, 2011). Any alcohol that the mother consumes goes into the bloodstream and, therefore, into the bloodstream of the fetus (Vorvick & Storck, 2012). Fetal Alcohol Spectrum Disorder describes five different levels of problems that can develop from a fetus exposure to alcohol. The most severe of these disorders is Fetal Alcohol Syndrome (FAS) with confirmed alcohol exposure. This diagnoses requires that the child have facial deformities, prenatal or postnatal growth retardation and evidence of neurocognitive defects. These defects may include, but are not limited to, issues involving attention and hyperactivity, memory difficulties, a lower IQ, and difficulties in arithmetic, verbal processing, and social understanding (Mukherjee, Hollins & Turk, 2006). The facial deformities are illustrated in Figure 1 from the National Institute of Alcohol Abuse and Alcoholism (NIAAA). In one of the most recent studies conducted in 2009, the prevalence rate of FAS in the United States was estimated to be between 2-7 per 1000. This same study showed that among younger school aged children, 2-5% have a FASD (May et al., 2009). These other disorders include fetal alcohol syndrome with no confirmed alcohol exposure, partial fetal alcohol syndrome, alcohol related neurodevelopment (ARND), and alcohol related birth defect (ARBD). Partial fetal alcohol syndrome has some symptoms seen in FAS and the child must have neurocognitive disabilities and some sort of facial deformities. Children with ARND have no growth problems no do they poses facial deformities; however, these children must have clear neurocognitive disabilities. Lastly, children with ARBD may have some of the facial features associated with FAS and behavioral features and structural abnormalities that are more distinct (Mukherjee et al., 2006). The latest estimates of the cost of FAS were determined in 2002 and were said to be 2 million for one individual over the course of his or her lifetime (Lupton, Burd & Harwood, 2004). Inflation has only caused this number to increase since then. There is also the risk of pregnancy termination and a risk for preterm delivery when alcohol is consumed during pregnancy (Albertson et al., 2004; Anderson, Anderson, Olsen, Gronbaek & Strandberg-Larsen, 2012).Figure 1: Facial Features of FAS and FASDssour

Healthy People 2020In the Healthy People 2020 objectives, there are two specific objectives under the Maternal, Infant, and Child Health category, which address the issue of alcohol consumption during pregnancy (U.S. Department of Health and Human Services, 2013). The first of these objectives is MICH- 11.1, which aims to increase abstinence from alcohol during pregnancy. The second of these objectives, MICH 11.2, goes hand in hand with the first but specifically addresses binge drinking during pregnancy. The existence of these two objectives shows that the consequences of the actions they address are severe enough, and prevalent enough, that they must be addressed at the national level. In addition, binge drinking while pregnant was given a separate objective, which shows that it requires specific attention. Binge drinking greatly increases a fetus exposure to alcohol and can only increase the fetus chance of developing health problems, if the pregnancy even makes it full term. With the risk of the child having moderate to severe physical and mental problems, and even the potential of death of the fetus, it is clear that there needs to be an intervening factor that aims to reduce, if not eliminate, the number of women who drink while pregnant. Intrapersonal factorsThere are many factors that have an influence on a womans choice to consume alcohol during her pregnancy. Some of these are internalized influences and are known as intrapersonal factors. Influences such as a womans attitude toward drinking during pregnancy, her knowledge of the risk and rewards of drinking during pregnancy, and even her personality and socio-economic status can play a role in her decisions as a mother-to-be.

AttitudesIt has been found that one of the strongest predictors of alcohol use during pregnancy is a womens attitude toward drinking while pregnant. An article published in BMC Public Health explains, women who disagreed with the statement that pregnant women should not drink were more likely to intend to drink alcohol during a future pregnancy as were women who had neutral or positive attitudes towards alcohol consumption in pregnancy, (Peadon et al., 2011). Even more so than attitudes, previous drinking habits is a very strong, if not the strongest, indicator of whether or not a woman will drink while pregnant. Women who consume alcohol on a regular basis before becoming pregnant are much more likely to continue drinking during their pregnancy (Chang, McNamara & Wilkins-Haung, 2006a). This may be due to an alcohol dependency that has formed or because of a belief that the risks are not significant enough to warrant quitting.KnowledgeAnother potential influence in a womans decision to consume alcohol during pregnancy is her knowledge of the risks, such as FAS or FASDs, associated with the behavior. Another BMC study, that was very similar to the one mentioned above, showed that 61.5% of women in the study knew the effects associated with alcohol consumption during pregnancy and 55.3% knew about FAS (Peadon et al., 2010). The amount of women that know and understand that risks associated with drinking while pregnant needs to increase from these current statistics, but that cannot be the complete solution to the problem. Many people assume that if there is sufficient knowledge of the potential health risks that can result from performing a behavior that there will be a change in the attitude toward that behavior; however, that is not always the case. In particular, this study showed that an increase in knowledge of the risks did not affect womens attitude towards drinking during pregnancy.Socio-economic Status and DemographicsAnother factor that can greatly affect this behavior are the socio-economic status (SES) and demographics of the woman. A study published in the American Journal of Public health on the influence of race and ethnicity on pregnant women showed that an African American womans education level did not affect her risk level for alcohol use during pregnancy, and that African American women at all levels of education were at equal risk (Perreira & Cortes, 2006). On the contrary, when the data collected from white women was analyzed it was found that education level did have an influence on the risk level for alcohol consumption and that those who were more educated had a higher risk of drinking during pregnancy than their less educated counterparts (Perreira & Cortes, 2006). Similarly, women who are of lower SES are more likely to discontinue alcohol consumption once they have determined they are pregnant (Callinan & Room, 2012).Race was also a key factor in that non-Hispanic women are at a greater risk for drinking alcohol during pregnancy than Hispanics (Chang et al., 2006a). Yet another intrapersonal factor that plays into whether or not a woman consumes alcohol during pregnancy is age. It has been found that older women are more likely to drink while pregnant before becoming aware that they are pregnant and are then less likely than their younger counterparts to stop drinking once they have discovered they are pregnant (Callinan & Room, 2012). Age can often be related to SES because younger pregnant women may not be as financially stable due to a lower education level or a lower income job. This could be a potential reason why both younger women and women of lower SES are both less likely to drink while pregnant. Psychological & PersonalityDrinking alcohol is a behavior that has a strong psychological basis. Because alcohol affects the brain and its ability to function properly, many people use it as an excuse to do what they please and then simply blame their behavior on the alcohol. One may consume alcohol in order to ease any awkwardness they may feel in a social situation or to help them forget the stress and burdens of life. One study that sought to show the relationship between personality and substance abuse during pregnancy showed that extraverted women, meaning women who find pleasure and happiness in social situations, were 74% more likely to drink during pregnancy (Ystrom, Vollrath & Nordeng, 2012). This could be attributed to the fact that extroverted women often feel the need to use alcohol in the social situations they place themselves in. This same study also showed that conscientious women had an 89% lesser chance of drinking during pregnancy. Conscientiousness was defined, in the study, as women who were responsible, self-disciplined, and inclined to adhere to social norms, (Ystrom et al., 2012). Psychological disorders can have a large impact on a womens alcohol dependency. Alcohol may be used as a way to cope with disorders such as anxiety and depression. Pregnant women with these disorders are at a greater risk for drinking while pregnant (Skagerstrom, Chang & Nilsen, 2011). Interpersonal Factors

In most cases, with the exception of women with an alcohol dependency, whether or not to consume alcohol during pregnancy is a choice that a woman must make. This choice is often influenced by a womans social surroundings, which may include friends, family, or a spouse. These outside influences from people who are in close relationship with the woman are known as interpersonal factors. Social support from the people that are prominent figures in a womans life can influence a womans decision to drink during her pregnancy. Social support might include providing encouragement for a woman to make healthy choices, providing resources for the woman to make those choices, or providing information that can allow the woman to make informed decisions regarding her pregnancy. One study found that social support during a womans pregnancy reduces the incidence of a woman drinking (Stephens, 2008). Having a strong support group allows a woman to feel more at ease about her pregnancy and reduces the chance of her turning to alcohol as a way of coping with the stresses of pregnancy. Having positive social support groups are especially important for woman who may belong to cultures that form networks to help expecting mothers (Clarren, Salmon, Jonsson & Wiley, 2011). The activities that social groups choose to partake in can affect a pregnant womans decision to drink. If a womans close friends choose to regularly go out and drink, the woman is more likely to partake in drinking in order to feel included and not feel isolated. Another significant interpersonal factor is the influence that stems from the father of the baby, or the partner of the pregnant woman. The drinking habits and drug usage of a womans partner can affect whether or not a woman drinks during her pregnancy (Chang et al., 2006a). This is often due to the father or spouse not giving the woman support to abstain from alcohol use during pregnancy. The partner may not be aware that pregnant women are to abstain from alcohol during pregnancy, or he or she may not realize the severity of the consequences of drinking during pregnancy. Both of these may lead to the male either encouraging or simply not discouraging a woman to drink, especially if there was a high prevalence of pre-pregnancy drinking for either partner. In addition, the partner may be the supplier of the alcohol and, therefore, be an enabler to the woman. It is important that both the woman and her partner understand the consequences of drinking while pregnant and work together to ensure that the woman abstains from alcohol throughout her pregnancy. Interpersonal influences can sometimes be negative and can lead to a woman being at a higher risk for drinking during her pregnancy. Abuse, whether it is physical or sexual, from a partner or anyone in relation to the woman increases the chance that a woman will partake in drinking during her pregnancy (Skagerstrom et al., 2011). The article gives multiple explanations for the increased risk of alcohol use during pregnancy when violence or abuse is present in the womans life. One explanation is that women often use alcohol as a way to cope with the emotional and physical pain that is associated with abuse. Another possible explanation is that women who drink during their pregnancy are abused because the people in her life disagree with her decision to drink. Lastly, abuse may ensue from a partner who abuses alcohol, and women whose partners drink are more likely themselves to drink (Skagerstrom et al., 2011). By reducing the risk factors that lead to a woman getting abused, the problem of alcohol consumption during pregnancy could be greatly reduced. Organizational FactorsWhile interpersonal factors are more proximal to a pregnant woman, organizational influences, although distal, can still have a significant impact on a womans decision to partake in or avoid alcohol consumption during her pregnancy. Organizations may be local or can exist on a statewide or national level and may serve various functions. The size and complexity of organizations can vary. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) is a national organization that seeks to communicate the negative effects of alcohol, including its negative effect on the health of a pregnant woman and her child (Gmel & Rehm, 2003). This group has done work to promote the dangers of drinking while pregnant since 1970. These works include organizing national research workshops for FAS, influencing the publication of the surgeon generals advisory against drinking while pregnant, creating the National Alcohol Screening Day, and many other achievements (NIAAA, 2013). This organization is one of the many ways that pregnant woman can obtain factual information that they can then use to make informed decisions about their alcohol consumption. The American Academy of Pediatrics has developed the Fetal Alcohol Spectrum Disorders Program that works with community and national level organizations to ensure that the negative effects of drinking while pregnant are made aware, the correct knowledge is disseminated, and there is a greater public health effort to combat FAS (Fetal Alcohol Spectrum Disorders). Large organizations like the NIH and AAP serve as information outlets for smaller organizations that work to prevent pregnant women from drinking during pregnancy. Examples of community organizations are local health units, behavioral health service organizations, local abuse treatment centers, and others. In Australia, interventionists interested in developing interventions to reduce the incidence of FASDs gathered community members, including community and consumer organizations, to discuss the communities and organizations feelings towards FASDs. In addition, they gathered to express what they believed would be the best approach to reduce the prevalence of these disorders (Jones et al., 2013). This inclusion of community members and organizations in the planning of interventions shows the impact that organizations play in determining whether or not a woman decides to consume alcohol throughout her pregnancy. Physical EnvironmentA womens physical environment can include the infrastructure that surrounds her. For example, a rural town with few health resource outlets may serve as the physical environment for a woman who is pregnant. A lack of organizations and community efforts that help educate women about the dangers of drinking while pregnant is one example of how the environment can influence a womans decision to drink while pregnant. Another way the environment can influence a womans decision to consume alcohol during pregnancy is the availability of alcohol. A woman may be more prone to consume alcohol if she is in an environment that is populated with liquor stores, bars, or wineries. While a woman does have the option to abstain from the pressures of her environment, it can often be difficult when there is a constant presence of alcohol in a womans life. PolicyIn the United States, there are policies in place that aim to reduce the prevalence of pregnant women drinking during pregnancy. It has been mandated by the government that a warning statement must be placed on all alcoholic beverages that states, according to the U.S. Surgeon General, pregnant women should not drink alcoholic beverages during pregnancy because of risk of birth defects, (International Center for Alcohol Policies, 2011). The inconspicuous placement of this label on all alcoholic drinks makes it more apt for pregnant women to see and, hopefully, adhere to its advice. Another policy that was put in place in 2013 is the policy that states that women who are pregnant and have alcohol and other substance abuse problems have priority for both private and public substance abuse treatments. Evidence of alcohol use during pregnancy can be used in child welfare proceedings according to another policy. This particular policy classifies alcohol exposure to a fetus as neglect or child abuse. This policy may work to show women the seriousness of alcohol consumption during pregnancy and aims at the ethos of women by explaining that drinking while pregnant is equivalent to physically abusing a child in the eyes of the law. Additional policies exist that address the rules regarding reporting a woman that may potentially be exposing her fetus to alcohol, the ability of the state to put a woman in custody for consuming alcohol during pregnancy, and rules regarding evidence that can be used in the criminal prosecution of a woman who consumed alcohol during pregnancy (Alcohol Policy Information System, 2013). There are currently 13 states that require that a woman report any substance in her pregnancy (SD & Musick, 2013). By denying any woman who reports substance abuse public assistance, state governments hope to discourage the use of alcohol during pregnancy. All of these policies and laws are put in place to protect the fetus and to try and prevent cases of FAS and FASDs from occurring.Factors Affecting BehaviorAll health behaviors are influenced by many factors. These influences are present throughout the process of deciding to partake in a behavior and continue to have an effect through the duration of performing that behavior. These influences can be categorized as predisposing, enabling, and reinforcing factors. Predisposing factors are the factors that influence an individual before taking on a behavior. These include knowledge, attitudes, beliefs, and values. Enabling factors are factors that facilitate a behavior and may be necessary in order for an individual to perform the behavior. Examples of enabling factors are personal aptitudes and environmental resources. Lastly, reinforcing factors influence an individual to continue to perform the behavior. Rewards and punishments are considered reinforcing factors (Bautista-Rentero et al., 2014).Predisposing Factors Possession of a negative attitude towards recommendations to abstain from alcohol during pregnancy (Peadon et al., 2011). Regular consumption of alcohol before becoming pregnant (Chang et al., 2006a). Lack of knowledge of risks associated with consuming alcohol during pregnancy and lack of knowledge about FAS (Peadon et al., 2010). African American women of all education levels and all non-Hispanics (Perreira & Cortes, 2006; Chang et al., 2006a). High education level among White women. (Perreira & Cortes, 2006). Possessing a higher socio-economic status (Callinan & Room, 2012). Age, with older women being at a greater risk for the behavior (Callinan & Room, 2012). Having an extravert personality type (Ystrom et al., 2012). Possessing a non-conscientious personality or someone who is irresponsible, has little or no self-discipline, or ignores social norms (Ystrom et al., 2012) Having a disorder such as anxiety or depression (Skagerstrom et al., 2011).Enabling Factors: Having limited or no access to workshops, information about FAS, and screenings conducted by the National Institute of Alcohol Abuse and Alcoholism (NIAAA, 2013). Limited or no access to health units, behavioral health services organizations, local abuse treatment centers, and other outlets that provide information and health services for pregnant women. Living in a community with a lack of efforts to educate pregnant women about the dangers of alcohol use. Lack of effort by Fetal Alcohol Spectrum Disorder Programs to disseminate information about FAS to the local community and promote a greater public health effort to stop women from drinking during pregnancy (Fetal Alcohol Spectrum Disorders). Living in an environment that provides high accessibility to alcohol and may contain many liquor stores, bars, and wineries. Living in an environment that does not enforce laws and policies such as policies that discourage women from drinking during pregnancy, allow a woman to be put in custody for drinking during pregnancy, or allow someone to report a woman who is suspected of drinking during her pregnancy (Alcohol Policy Information System, 2013). Required Surgeon Generals warning labels regarding the harm of drinking during pregnancy not being placed in a strategic place that is easily visible and easy to read (International Center for Alcohol Policies, 2011).Reinforcing Factors Lack of peers and family members providing social support such as providing encouragement for a woman to make healthy choices, providing resources for the woman to make those choices, or providing information (Stephens, 2008). Lack of support group in cultures that rely on networks that support expecting women (Clarren et al., 2011). Having friends or peers that regularly partake in activities that involve drinking. Having a spouse or partner that regularly drinks (Chang et al., 2006a). Abuse, whether it is physical or sexual, from a partner or anyone in relation to the woman (Skagerstrom et al., 2011).

Predisposing FactorsThe predisposing factors listed above are factors that are associated with the individual partaking in the behavior, in this case a woman who chooses to consume alcohol during her pregnancy. These factors encompass the womans beliefs, attitudes, knowledge, and values regarding drinking during pregnancy. In addition, this category of factors includes the socioeconomic status, age, and race of the woman. Of these factors, it was shown that the most significant predictor of whether a woman choses to consume alcohol during her pregnancy is previous drinking habits before becoming pregnant (Chang et al., 2006a). This is a factor that could be targeted in an intervention whereas race, age, and socioeconomic status cannot be altered. These predisposing factors are ultimately what drive a womans choice to drink during her pregnancy or abstain from alcohol.Enabling FactorsPredisposing factors can often be highly linked to both enabling and reinforcing factors. Enabling factors are the factors that facilitate a womans choice to drink during pregnancy. These factors may include community efforts to disseminate information, provide outlets for help, local and national organizations that provide resources, or laws and regulations concerning the behavior. A community with a lack of resources such as health units, health behavioral services organizations, and abuse centers may influence a woman to believe that drinking during pregnancy is not a problem or may limit her breadth of knowledge on the risks associated with drinking during pregnancy. Enabling factors allow the woman to continue drinking during her pregnancy because there is no force that is providing encouragement to stop.

Reinforcing FactorsReinforcing factors, or factors that encourage or discourage continuation of drinking during pregnancy, are also linked to predisposing factors. Reinforcing factors include the relationships that people have with their peers, family, and other significant people in their life. These close relationships often influence the beliefs, attitudes, knowledge, and values that one possesses. For example, if a woman is lacking a social support group that can encourage her to abstain from drinking during pregnancy, she is more likely to believe that drinking is not harmful to her, and she is more likely continue to drink during her pregnancy (Stephens, 2008). Social Ecological Model

Theories and Models Theories and models are used to explain the complicated processes that individuals go through when performing a health related behavior. In addition, models and theories are used to design interventions to promote health behaviors or aid in the cessation of behaviors. For example, the Information-Motivation-Behavioral Skills Model was initially developed to prevent HIV (Fisher, Fisher & Harman, 2003). While many theories and models have been used to address the issue of alcohol consumption among pregnant women, the Integrated Model of Behavior and Transtheoretical Model are two models that address a wide range of factors that lead to an individual performing a behavior and the steps that are needed to make a behavior change. Integrated Model of Behavior (IBM)One model that has been used in designing interventions for the prevention of consumption of alcohol during pregnancy is the Integrated Model of Behavior (IBM). This complex model emphasizes and individuals intention to perform a behavior and the factors that lead to intention. These factors include attitudes toward the behavior, the perceived norms regarding the behavior, and an individuals personal agency. The model also shows that salience, knowledge and skills, environmental constraints, and habits have an effect on an individuals behavior. An intervention designed by Project Choices used this model in order to create tailored interventions for a group of women at a high risk for AEP (alcohol exposed pregnancy). By reducing the level of alcohol consumption on a regular basis and increasing contraceptive use, interventionists hoped to reduce the incidence of AEP. After recruiting the women and conducting an elicitation study to ensure that the program would be effective, the intervention began and was based on four counseling sessions and a visit to a contraceptive counselor. The construct of attitude was addressed at each of the four counseling sessions by having periods of discussion in which participants were able to discuss alcohol use and her readiness to change. In this time period, attitudes on drinking were discussed so that interventionists could understand the attitudes that the women had towards drinking and tailor interventions to address these attitudes; however, it was not stated how these attitudes were measured. Personal agency was greatly stressed in this intervention program. The counseling sessions aimed to help women decrease the temptation to partake in the behavior, which helped to increase the womens perceived control over the situation. In addition, the sessions worked to increase confidence to avoid drinking during pregnancy, which targets the self-efficacy of the participants. The counseling sessions did not directly address the perceived norms construct of IBM. Counselors informed the participants of their drinking level in comparison with the average drinking level of the women in her age group, and then the participants were asked how they felt about this. This discussion prompted participants to address what they perceived was the norm regarding alcohol consumption, but there was not a specific discussion regarding the participants perceived norms, or their beliefs of what they perceived others expected of them concerning the behavior. Knowledge and skills were addressed in both the counseling sessions and the contraceptive counseling visit. In the regular counseling sessions, participants were given brochures about alcohol and birth control methods, and the risks of alcohol-exposed pregnancies were discussed. The contraceptive visit gave the women with high alcohol use the skills needed to prevent a pregnancy in which the fetus could be harmed from the high rate of alcohol consumption of the mother. Salience was addressed as women were asked how important it was for them to consume alcohol at a safe level and was measured using a scale. Environment of the participants was also addressed in this intervention. Interventionists aimed to create an intervention that provided a positive and welcoming environment to draw in women who are dealing with retaliatory environments in their everyday lives. Participants were provided with information and access tools for abuse treatment centers in order to address the habit construct of the model. To measure the effectiveness of this intervention, surveys were given to the women 9 months after the intervention to see the reduced risk of AEP; however the constructs before and after the intervention were not measured so there was no evidence for improvement in any specific construct area. The intervention conducted by Project CHOICES also incorporated the stages of change construct of the transtheoretical model. These constructs were used in helping to identify the type of intervention needed for each woman. Women who were unaware that they were at risk for AEP or unaware of what AEP is (pre-contemplation) were given different intervention plans that those women who were in the contemplation stage and were aware that they needed to make a change in their drinking and contraceptive habits (Velasquez et al., 2011). Transtheoretical ModelTranstheoretical model has also been used as the basis for interventions to reduce alcohol exposure during pregnancy. In this model, there are four over-arching constructs that each has multiple components. Stages-of-change, decisional balance, self-efficacy, and processes of change are the four over-arching constructs of transtheoretical model. An article published in the Journal of Substance Abuse Treatment explains a study that used this model to create interventions that addressed alcohol consumption during pregnancy. The stage-of-changes construct was addressed in this intervention but was limited to three stages rather than the typical 5 stages. The three stages were defined as pre-contemplation, contemplation, and action. In the pre-contemplation phase, the individual is not considering making a change in the near future. When the individual begins to become aware of the problem and is considering making a change, he or she has moved into the contemplation stage. The last stage, action, occurs when the individual changes his or her behavior related to the problem. A Readiness to Change Questionnaire was administered to measure, which stage-of-change each participant resided in. The decisional balance construct of the model was not used in this study, and it was not specified as to why it was not used. Self-efficacy, which consists of confidence to perform a healthy behavior and the temptation to engage in an unhealthy behavior, was measured using an Alcohol Abstinence Self-Efficacy Scale (AASE). This scale measured cue strength, an individuals perceived temptation to drink, and an individuals confidence in abstaining from alcohol when given 20 common scenarios that would potentially tempt the individual to use alcohol. The final construct, process of change, is not discussed in depth in this study, but it is noted that a brief intervention was conducted in which participants were given information on the health implications of drinking during pregnancy. This administration of information is an example of the consciousness-raising component of processes of change. In order to measure the effectiveness of the intervention, women were asked to report their alcohol use (including number of days drinking and number or drinks consumed) before and after the intervention. The study showed that women who consumed the largest amount of alcohol before the intervention showed the greatest reduction in consumption after the intervention. In addition, these reports showed that women in pre-contemplation stage did consume more alcohol on more days than women in the action stage, but state-of-change cannot be used to predict alcohol consumption. The only construct that was shown to be able to predict whether or not a woman will consume alcohol during pregnancy was temptation, which was measured using the AASE (Chang , McNamara, Wilkins-Haung & Orav, 2006b).Interventions

In order to address the problem of women drinking during pregnancy, there have been multiple interventions proposed and implemented by different interventionists. Many of the interventions that were proposed or implemented followed a general pattern in which at risk women were brought in and their alcohol consumption habits recorded. After determining the womens current drinking habits, interventionists work with the women in either group or individual settings to educate them on the dangers of drinking during pregnancy, determine goals for reducing drinking habits, and then evaluate the womens progress after a few months. One particular intervention, that was performed in the resident and faculty obstetric practices of the Brigham Womens Hospital, targeted 123 pregnant women and consisted of 6 steps. First the womans general health information and information on the course of the pregnancy was collected, and then the woman was asked how she has changed her lifestyle since becoming pregnant. From there the participant was asked to identify her goals for alcohol consumption during her pregnancy and was asked to explain why she held these goals. The fourth step was to have the woman determine situations in which she would be tempted to drink, and then the fifth step was to work with the interventionists to come up with alternatives to drinking in those tempting situations. The last step was to drive home 4 key points from the intervention drinking goals during pregnancy, reasons for having those goals, situations of temptation, and alternatives to drinking in those tempting situations. Each woman identified why they wanted to make drinking goals for their pregnancy and then each woman was aided in developing strategies to increase their control over drinking. Self-efficacy, or ones confidence in their ability to perform a health behavior, was addressed by giving the woman alternative options to drinking in situations that the woman personally identified as tempting (Chang, Goetz, Wilkins-Haug & Berman, 2000). Proposed InterventionA proposed intervention would incorporate many of the ideas seen in the intervention above and also ideas from other similar interventions. The intervention would be designed using the Integrated Behavior Model because it is a complex model covering many constructs that are important in implementing change in a persons behavior. The targets for the intervention would be women who are between the ages of 20 and 35 because this age group is the most fertile of any other age group (Liu & Case, 2011). The intervention would consist of 5 different small group sessions, each serving to address the different constructs of the Integrated Behavior Model. Before the sessions begin, the participants would be asked to take a T-ACE assessment, which is used to identify the participants that are risk drinkers, as well as identify their contraceptive use (Allen & Wilson, 2003). Women who had a positive T-ACE assessment would be included in the study. The first session would address the womens attitudes towards drinking during pregnancy. Participants would be asked what knowledge they have of the risks of drinking during pregnancy and asked to share any experiences they have had with FAS or FASDs. The women in the intervention would also be given information on the statistics of FAS and FASDs and would be instructed that no amount of alcohol is safe during pregnancy. This portion of the intervention would specifically address the intrapersonal level of the Social Ecological Model, as women would ultimately be using their beliefs to form an attitude about drinking during pregnancy. By building these attitudes and providing alarming information on the dangers of drinking during pregnancy, this intervention level has the potential to increase the saliency of the behavior to the women. In the second session, perceived norms would be addressed. Participants would be asked what they believe the prevalence of women who drink during pregnancy is and also asked what they believe the people in their lives expect of their behavior during pregnancy. Asking the participants these questions and then providing the current statistics of women who drink during pregnancy addresses injunctive and descriptive norms. This session targets the interactions between the woman and the people in her life that she values (interpersonal level of SEM). The aim in showing participants the actual percentage of women who drink during pregnancy is to show that drinking during pregnancy is not something that is condoned as exemplified by the low percentage of women that actually partake in the behavior. This session also allows women to see the people in their life who disapprove of drinking during pregnancy as motivation to abstain from alcohol use. The third session would address personal agency, or the womans belief that she can abstain from alcohol during her pregnancy. This session would be much more involved. Using ideas from the study done in Brigham Womens Hospital, the session would require that the woman to create drinking goals for their pregnancy and then identify situations where there would be a temptation to drink (Chang et al., 2000). Working as a group, women would come up with ways that they could avoid these situations or find alternatives to drinking in these situations. This phase of the intervention targets the intrapersonal level of the SEM by increasing the participants self-efficacy to abstain from alcohol during their pregnancy. In addition, this phase may work on the interpersonal level as participants build relationships with other session members. These relationships can serve as outlets of motivation to aid the women in staying focused on her individual goals. The fourth session is a key session because it provides participants with the knowledge to avoid unwanted pregnancies and helps prevent women from drinking in the early stages of pregnancy before becoming aware of pregnancy. In this session, women would be setup with an OBGYN who will determine the best contraceptive method for the participant and prescribe or distribute that birth control method. This idea was used in an intervention designed by Project CHOICES (Velasquez et al., 2011). This session will also provide the women with information to get counseling for alcohol addictions and encourage women to seek out help if needed. This level of the intervention utilizes the services that the community provides and requires cooperation from the community. By involving the community, participants see that their effort to combat drinking during pregnancy is supported by the people in their community. The last session involves the participants becoming the teachers. This last session would allow participants to invite their family, friends, and community members to the session. During this session the participants would teach their guests what they have learned throughout the course of the intervention. In using the teach back method, interventionists can be sure that the participants understand the information given to them well enough to teach it to their loved ones. Educating the guests on the information about the dangers of drinking during pregnancy and the goals each woman has set for her pregnancy creates a positive environment for the woman and helps build support groups as she works to abstain from alcohol. Conclusion Fetal Alcohol Syndrome and Fetal Alcohol Syndrome Disorders are completely preventable, but only if the source is properly addressed. In order to halt the occurrence of these disorders, preventative measure must be taken to ensure that women do not consume alcohol during pregnancy. The theories and models that have already been established need to be utilized to create and implement additional interventions that target not only women but also to members of the community, organizations, and even policy makers. Reaching all levels of the Social Ecological Model is important in ensuring that the interventions will truly have an impact and will have a more lasting impact. The proposed intervention above is just one of many possible interventions that can potentially eliminate FAS and FASDs by targeting the health behavior of alcohol consumption among pregnant women.

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