A Survey of Health Care Professionals’ Knowledge and Experience of Foetal Alcohol Spectrum Disorder and Alcohol Use in Pregnancy

BackgroundLittle is known about media portrayals of alcohol use in pregnancy and fetal alcohol spectrum disorder (FASD). The media has an important role in informing the public about the potential for alcohol harms to the unborn child and shaping community understanding and attitudes toward alcohol use in pregnancy and FASD. This scoping review aimed to identify and analyze publications that explore how alcohol use in pregnancy and FASD have been portrayed in the international media across two decades.MethodsFive databases were searched for peer‐reviewed, English‐language articles published in the medical literature between January 2004 and June 2024 that reported perceptions of, or analyzed content on, alcohol use in pregnancy and FASD in a variety of media types. Thematic analysis was used to identify themes across and between different types of media.ResultsWe identified 18 relevant articles that analyzed content from newspapers (n = 7), online discussion forums (n = 4), Twitter (X, n = 3), Facebook (n = 1), television (n = 1), and mixed media (n = 2). Of these articles, 11 focused on alcohol use in pregnancy, two on FASD, and five on both. Five themes were identified: (1) Contradictions in messaging between media sources regarding alcohol harms; (2) Concerns about harm to children, mothers, and society; (3) Expectations of motherhood; (4) Stigma, stereotypes, and shame associated with alcohol use in pregnancy and FASD; and (5) Advocacy for FASD prevention and support.ConclusionsContradictory information provided within and between media sources sends mixed and potentially confusing messages about pregnancy‐related alcohol harms. Messages must avoid stigmatizing pregnant women and individuals living with FASD. To raise awareness of alcohol harms and help prevent FASD, media communications must go beyond providing recommendations from alcohol use guidelines. Messaging should be culturally appropriate, strengths‐based, and acknowledge the multiple drivers of alcohol use in pregnancy.

Fetal alcohol syndrome: Diagnosis, epidemiology, and developmental outcomes, CM O'Leary In an excellent review of fetal alcohol syndrome (FAS) published in this issue1, Colleen O'Leary outlines the essential diagnostic criteria for FAS − the triad of growth retardation, abnormal facial features and CNS anomalies in the context of known exposure in utero to alcohol. She describes the numerous clinical features that may be seen in affected children but alludes to the fact that FAS represents only the 'tip of the iceberg' when it comes to the range of outcomes, including behavioural and cognitive dysfunction, that may result from fetal exposure to alcohol. Information presented about the epidemiology of FAS outside Australia suggests a birth prevalence ranging from 0.26 per thousand live births (in middle to upper class Caucasians in the USA)2 to an astounding 39 per 1000 live births (in the predominantly black population of The Western Cape Province in South Africa)3. Differences between rates may change over time and are attributed to a range of risk factors including ethnic diversity, socio-economic status, maternal age, concomitant abuse of other substances, and genotype. Clearly, the criteria used to diagnose FAS, the method of case ascertainment, knowledge of drinking patterns during pregnancy, and the extent to which children have access to specialized paediatric services may also influence rates. One message, however, is clear from these data. Rates of FAS in Indigenous communities − whether American Indians, South Africans, Canadians or Alaskan Natives − are much higher than in non-indigenous individuals. So how common is FAS in Australia and does it occur more frequently in our indigenous communities? O'Leary's review highlights the paucity of published Australian data on FAS. In 1978 a series of six children affected by maternal alcoholism was reported in the MJA by Collins and Turner4'to increase awareness of the FAS in Australia.' Case series published by Walpole and Hockey in 19805 and Lipson et al. in 19836 included a total of only 27 children, 22% of whom had an Aboriginal mother. In a recent issue of this Journal, Harris and Bucens7 conducted a retrospective case note review of children born in the Top End of the Northern Territory between 1990 and 2000. Inpatient and outpatient notes of all children with conditions corresponding (by International Classification of Diseases (ICD) 9 or ICD 10 code) to fetal alcohol syndrome, microcephaly, fetus or newborn affected by maternal use of drugs of addiction, mental and behavioural disorders due to alcohol, or drug withdrawal syndrome in the newborn were reviewed. Seventeen children fulfilled the diagnostic criteria for FAS. All were Indigenous. Based on this number of cases, birth prevalence was estimated at 0.68 per 1000 live births or 1.7 per 1000 indigenous live births. The authors acknowledge this may be an under-estimate. If, for example, the additional 26 children (all Indigenous) that they determined to have 'partial FAS' or 'alcohol-related neuro-developmental disorder' actually have FAS (but documentation in the records was insufficient to make the diagnosis), then rates would increase to 1.87 per 1000 live births and 4.7 per 1000 Indigenous live births. The only other estimate of birth prevalence in Australia comes from a Western Australian study, in which Bower et al. report combined data from the WA Birth Defects Register and the Rural Paediatric Services Database8. The overall rate of FAS was 0.2 per 1000 live births (0.02 per 1000 live births in non-Aboriginal children − one of the lowest rates reported worldwide − and 2.76 per 1000 live births in Aboriginal children). These rates are considered by the authors to be an underestimate of the true prevalence of FAS. An ongoing study using the Australian Paediatric Surveillance Unit (APSU) mechanism for case finding through paediatricians will go some way to providing baseline data on the national FAS rate in Australia9. Preliminary data from 2001 to 2002 suggest an overall birth prevalence lower than that in the WA study, and with an over-representation of Indigenous children. However, the APSU study has limitations and is also likely to result in an underestimate of the true FAS rate. Accurate determination of FAS rate is thwarted for a number of reasons. First, many rural, low socio-ecomomic and Indigenous communities have poor access to specialized paediatric and obstetric services and many do not access antenatal care until late in pregnancy. Second, the detailed clinical data required for the diagnosis of FAS (including birth weight, height and head circumference, growth velocity and facial features) are often poorly recorded in medical notes. Third, retrospective documentation of the extent of alcohol consumption during pregnancy is notoriously unreliable, and this information is often not sought or recorded prospectively. Fourth, the diagnosis of FAS in young infants generally, and recognition of the facial features in Indigenous infants in particular, is difficult. As a result the diagnosis is frequently delayed or never made. Finally, although there is no published information on the knowledge of Australian health professionals about the diagnosis or management of FAS, there is evidence from the US that health professionals there are ill informed about FAS10. As part of the Research Study of Fetal Alcohol Syndrome in Australia, which also includes the APSU study and a review of contemporary data on alcohol use in pregnancy, we are currently surveying obstetricians, general practitioners, Aboriginal and allied health professionals, and community nurses to obtain Australian data. Worryingly, in a South Australian survey of general practitioners published in 1992, only 42% of GPs could identify the hazardous daily level of alcohol intake for women, as defined by the National Health and Medical Research Council (NHMRC) at that time11. The NHMRC Australian Alcohol Guidelines have recently been updated for women who are pregnant or might soon become pregnant (Table 1, Guideline 11)12. However, these recommendations are complex and it is important to know how well they have been disseminated to and understood by health professionals, and how reliably they are communicated to women. If, as we suspect, these guidelines are difficult to operationalize, they will need revision, simplification and wide dissemination. Educational programs are essential for health workers at all levels to provide them with the skills required to screen for alcohol intake in pregnancy, to counsel women at risk, and to ensure early recognition of FAS and referral of children to appropriate services. Children with FAS frequently have behavioural, developmental and cognitive problems. APSU data suggest that these children use a range of specialist paediatric, child development, disability, community, remedial education, respite and psychological medicine services9. Fetal alcohol syndrome has been described as a 'preventable tragedy'.13 However, identifying interventions to prevent FAS requires consideration of the antecedent risk factors. Some risk factors cannot be modified, including maternal genotype for alcohol dehydrogenase, which may influence alcohol intake, metabolism, and fetal effects14. The causal pathway we have developed (Fig. 1) acknowledges that FAS is the end result of a complex interaction between diverse social, political, environmental, and genetic risks. FAS is also the beginning of a lifelong and intergenerational pathway to physical, social and mental ill-health. Overlying this causal pathway are issues specific to our Indigenous population, such as the effects of colonization, marginalization, and loss of traditional culture15. Addressing these issues will be an important part of any FAS initiative in Indigenous populations. Causal pathway to fetal alcohol syndrome. We have identified a number of points at which the pathway to FAS might be interrupted (Fig. 1). Interventions with the most impact are those that could be applied at the top end of the pathway. However, these are also the most difficult to implement. Prevention of FAS is not a problem for health alone, but for a range of portfolios including housing, justice, education, and community services. For example, a reduced societal acceptance of alcohol use might decrease the use of alcohol in women. In Australia, several Indigenous communities have completely banned alcohol in an attempt to minimize some of its negative effects. These include lack of supervision and inadequate nutrition of children, unemployment, domestic violence, non-accidental injuries, accidents and motor vehicle accidents. Improvements in maternal education and access to health services (including antenatal care and contraception) might also decrease fetal exposure to alcohol. Similarly, the provision of better employment opportunities, housing and education, as well as decreasing rates of substance abuse and domestic violence, may also have an impact on alcohol intake. Preliminary data from the APSU9 indicate that many mothers of children with FAS used, in addition to alcohol, a range of addictive and other drugs during pregnancy, including heroin, solvents and cocaine. Few of the mothers had progressed beyond secondary education and as few as one third of children reported with FAS were currently living with a biological parent, many having been placed in foster care. Around half the mothers had more than one child with FAS − a shocking statistic that highlights our failure to protect children most at risk. Interventions at the bottom end of the causal pathway will provide only 'band-aid' solutions to the problem of FAS. Nevertheless, access to specialist health and educational services must be assured for children with FAS, who may have multiple disabilities. Education of affected children and their siblings regarding the perils of alcohol abuse, as well as measures to control access to harmful substances, may go some way to preventing FAS in the next generation. There are encouraging signs of increased interest in FAS in Australia. A recent episode of the SBS series Living Black16 featured FAS and a National Workshop on Fetal Alcohol Syndrome was convened by the Australian National Council on Drugs and the National Expert Advisory Committee on Alcohol in 200217. A literature review of FAS was undertaken on behalf these organizations18, on which Colleen O'Leary's report in this issue of the Journal is based1. In September 2003 a conference highlighting FAS was run by the Indigenous Children's Services Unit of the Queensland Council of Social Service in Townsville. It is timely to build on this momentum. There is an urgent need for research to provide accurate information on the frequency of FAS in specific communities and to evaluate the feasibility and efficacy of potential interventions to interrupt the causal pathway to FAS. The Research Study of Fetal Alcohol Syndrome in Australia is funded by Healthway WA. The Australian Paediatric Surveillance Unit is funded by the Department of Health and Ageing and is a Unit of the Division of Paediatrics of the Royal Australasian College of Physicians. We thank Ms Jan Payne from the Telethon Institute for Child Health Research, Perth, WA for supplying data for this article.

Fetal alcohol spectrum disorders (FASDs) describe a range of effects that can occur in children whose mothers drank alcohol during pregnancy. These effects can include lifelong behavioral and learning problems and, in some cases, physical problems. Fetal alcohol syndrome (FAS) is a condition associated with the most severe physical and functional impairments. While FAS and the corresponding abnormal facial features, growth, and central nervous system problems are best known, clinicians should recognize that FASDs refer to the entire spectrum of problems, from mild to the most severe FAS impairments. FASD, risky drinking, and alcohol use in pregnancy are timely topics for social work focus, as growing rates of heavy alcohol use and binge drinking among women present serious health consequences. In the United States, up to one in twenty US school children are living with FASD. Moreover, negative outcomes from alcohol use during pregnancy and FASD occur in every social, economic, and demographic group, among social drinkers as well as heavier drinkers. Social workers across practice settings can support positive health and social outcomes by learning more about FASD, participating in screening, assessment, and referrals; providing FASD-informed services; and advocating for individuals and families living with FASD. Two behaviors must occur simultaneously to put any woman at risk of an alcohol-exposed pregnancy (AEP): (a) drinking alcohol, and (2) not using contraception effectively or at all. Nearly half of all pregnancies in the United States are unintended, and over half of US women (53.6 percent) of reproductive age report using alcohol, with up to 29 percent of women aged 21 to 24 reporting binge drinking. Among pregnant women, 1 in 10 report drinking alcohol during pregnancy. When alcohol use and pregnancy occur together, a woman may have a child with FASD. Therefore, when considering how to prevent an AEP and a possible FASD, a discussion with a woman who is drinking alcohol must include whether she is using contraception effectively. Social workers can put prevention into practice by screening clients for risky alcohol use (alcohol screening and brief intervention), talking to women about their drinking and contraception, and providing counseling and referral when needed. The key message is simple: No amount of alcohol is known to be safe during pregnancy. Despite the prevalence of FASD and the lifelong problems it can cause for individuals and families, the literature on FASD is relatively sparse compared to other areas of study. However, a body of literature on prevention, screening, referral, and treatment for women who are at risk for alcohol-exposed pregnancies and some excellent resources for working with individuals and families with FASD, along with a number of excellent online resources, is growing.

1. Helen M. Thackray, MD* 2. Cynthia Tifft, MD, PhD† 1. 2. *Clinical Fellow, Medical Genetics Branch, National Human Genome Research Institute, Bethesda, MD. 3. 4. †Chair, Department of Medical Genetics, Children’s National Medical Center, Washington, DC. Objectives After completing this article, readers should be able to: 1. Describe the signs of fetal alcohol syndrome in the context of in utero exposure to alcohol. 2. Describe the relationship of facial characteristics and neuorobehavioral findings in fetal alcohol syndrome with age. 3. Compare and contrast the neurobehavioral aspects of children who have fetal alcohol syndrome with children who have other diagnoses and similar intelligence quotients. 4. Delineate the causes of fetal alcohol syndrome. Alcohol is the most common human teratogen, but its significant physical and neurobehavioral effects are completely preventable. Fetal alcohol syndrome (FAS) was described initially in case reports by Lemoine in 1968 and Jones and Smith in 1973. It is a pattern of physical, behavioral, and cognitive abnormalities seen in individuals exposed to alcohol in utero. The association between these findings and maternal use of alcohol during pregnancy has been well documented, with studies in both animals and humans suggesting teratogenicity from as little as one binge drinking episode in early pregnancy. The diagnostic criteria are not a result of fetal physical dependence or addiction or the presence of alcohol in the neonate at delivery; rather, they are teratogenic effects caused by in utero exposure to alcohol in the mother’s blood. In 1996, following a congressional mandate that the Institute of Medicine and National Academy of Sciences study FAS and related birth defects, these institutions published a review of the current understanding of FAS and revised the diagnostic criteria. Despite increased awareness of this preventable birth defect, new cases continue to occur in significant numbers and are routinely under-recognized by medical personnel. It is imperative that maternal alcohol use and its sequelae be considered and addressed in daily pediatric practice. The purpose of this article is to review the diagnosis, epidemiology, management, prognosis, and prevention of FAS. FAS represents a …

Fetal alcohol spectrum disorders (FASD) are increasingly recognised throughout Australia as important, but preventable, disorders that result in lifelong problems with health and learning, mental health, behaviour and substance misuse. The role of this article is to highlight current efforts, which are in their infancy, to recognise and prevent FASD in Australia. A federal parliamentary inquiry into FASD (2011), development of an Australian Government 'action plan' to prevent FASD (2013) and the announcement in June 2014 of government funding to progress the plan and appoint a National FASD Technical Network have focused attention on the need for FASD prevention in Australia. Other welcome developments include the formation of Parliamentarians for the Prevention of FASD (2011), revision of guidelines regarding alcohol use in pregnancy by the National Health and Medical Research Council (NHMRC; 2009) and provision of targeted funding for FASD research by the NHMRC (2013). Initiatives by Indigenous communities to restrict access to alcohol and diagnose and prevent FASD have had a significant impact in high-risk communities. The National Organisation for FASD has an important ongoing advocacy and educational remit. Nongovernment organisations such as the Foundation for Alcohol Research and Education have contributed to prevention by developing resources to assist health professionals to advise women about the harms of alcohol use in pregnancy; encouraging men to abstain from alcohol during the pregnancy; drafting a national plan; and advocating for pregnancy warning labels on alcohol. Internationally, in 2014, a charter on prevention of FASD was published in The Lancet Global Health, and the World Health Organization released guidelines for identification and management of substance use in pregnancy. Early recognition and support for individuals with FASD is crucial to prevent adverse secondary outcomes; however, primary prevention of alcohol use in pregnancy, and hence FASD, should be our future goal. The causal pathway to drinking in pregnancy is complex and requires a broad social ecological approach. Prevention will take time, must involve all government sectors and should incorporate primary, secondary and tertiary strategies to target both the broader community and populations at high risk of alcohol use during pregnancy.

Health professionals in the UK and internationally often lack knowledge of prenatal alcohol exposure (PAE) and fetal alcohol spectrum disorder (FASD). Raising awareness of PAE and FASD across health and social care sectors is vital to support Scotland's implementation of neurodevelopmental pathways. This study evaluated whether engaging in the Fundamentals of FASD contributed to change in (i) attitudes toward the health advice given to pregnant women, (ii) attitudes toward PAE, (iii) attitudes toward FASD, and (iv) knowledge of FASD. Furthermore, this study examined whether knowledge and attitudinal changes are maintained to 12 months posttraining. A total of 1327 attendees attended across 14 workshops. Of these, 1005 completed an initial evaluation questionnaire assessing their attitudes and knowledge toward PAE and FASD (pretraining ["T1"]). Repeated-measure follow-up responses were collected immediately after training ("T2"; n = 525); at 3 months ("T3"; n = 128); and at 12 months ("T4"; n = 157). Linear mixed models revealed trainees demonstrated significant improvement on all measures at posttraining but demonstrated a varied pattern at the T3 and T4 follow-up. Attitudes toward the health advice about alcohol use in pregnancy and alcohol use in pregnancy generally demonstrated no change between T2 and T4, indicating improvement was sustained from T2 to T4. In contrast, attitudes toward FASD and FASD knowledge were observed to significantly decline from T2 through to T4, albeit remaining higher than the pretraining. Attending the Fundamentals of FASD was associated with significant improvement in knowledge and attitudes toward PAE and FASD. A decline in FASD knowledge across time, albeit remaining above pretraining scores suggests ongoing or refresher training is required. Provision of training within continuing professional development frameworks may help sustain awareness and encourage healthcare professionals to be better equipped in supporting individuals affected by PAE and/or FASD.

To measure paediatricians' knowledge, attitudes and practices regarding foetal alcohol syndrome (FAS) and alcohol use during pregnancy. Postal survey of paediatricians in Western Australia in 2004. Of 179 eligible paediatricians, 132 (73.7%) responded (90 consultant paediatricians and 42 paediatric trainees). Of the 132 respondents, 18.9% identified all four essential diagnostic features for FAS. Only 49.2% had previously diagnosed FAS (range 1-30 cases) but 91.7% had seen children diagnosed by others; 76.5% had suspected but not diagnosed FAS; 12.1% had been convinced of but not recorded the diagnosis; and 31.8% had referred children for diagnostic confirmation. Although 79.6% agreed early diagnosis might be advantageous, 69.6% said diagnosis might be stigmatising and 36.4% thought parents might resist referral for assessment and treatment. Although 78.2% agreed avoiding binge drinking may reduce FAS, only 43.9% believed women should abstain from using alcohol in pregnancy. Only 4.5% felt very prepared to deal with a patient with FAS: most wanted educational materials for themselves (69.7%) and child carers (71.2%). Only 23.3% routinely ask about alcohol use when taking a pregnancy history and 4.2% routinely provide information on the consequences of alcohol use. Only 11.4% had read the current Australian national health guideline regarding alcohol consumption in pregnancy and 9.1% provided advice consistent with the guideline. Paediatricians identified the need for educational materials about FAS and alcohol use in pregnancy for themselves and their clients. Lack of knowledge about FAS diagnosis and management will limit opportunities for diagnosis, prevention and early intervention.

Prenatal alcohol exposure and fetal alcohol spectrum disorders (FASDs) remain critical public health issues. Alcohol use in pregnancy is a leading preventable cause of birth defects, developmental disabilities, and learning disabilities. Alcohol screening and brief intervention (SBI) is effective at reducing excessive alcohol use. However, this clinical preventive service remains critically underutilized in primary care. In 2014, the Centers for Disease Control and Prevention called for the creation of FASD Champion programs to promote clinician education about FASDs. Six professional health organizations and groups providing reproductive and child health services set out to create FASD Champion programs. The American College of Obstetricians and Gynecologists FASDs Prevention Program was created to focus on reducing alcohol-exposed pregnancies. The American Academy of Pediatrics' Champion program maintains the goal of improving health outcomes for children with FASDs by improving pediatricians' diagnostic capacity. The American Academy of Family Physicians has prioritized training family physician champions to improve the delivery of alcohol SBI among adult patients. The University of Alaska Anchorage has partnered with the National Association of Nurse Practitioners in Women's Health, the American College of Nurse-Midwives, and the Association of Women's Health, Obstetric, and Neonatal Nurses to assure advanced practice registered nurses and midwives have the knowledge and skills to prevent alcohol-exposed pregnancies and FASDs. The American Association of Medical Assistants has prioritized expanding the knowledge and skills of medical assistants related to promoting alcohol-free pregnancies. Finally, the Champions program at the University of Texas at Austin was established to train health social workers in alcohol SBI. Through the advocacy, education, and mission of these 6 health sectors in collaboration with national organizations and educational institutions, the evidence-based approach of alcohol SBI is being disseminated throughout the United States to reduce the harmful effects of prenatal alcohol exposure.

Elliott, E. (2014). Australia plays ‘catch-up’ with Fetal Alcohol Spectrum Disorders. The International Journal Of Alcohol And Drug Research, 3(1), 121-125. doi:http://dx.doi.org/10.7895/ijadr.v3i1.177Australians are amongst the highest consumers of alcohol worldwide, and "risky" drinking is increasing in young women. Contrary to the advice in national guidelines, drinking in pregnancy is common. Many women don’t understand the potential for harm to the unborn child and 20% have a "tolerant" attitude to drinking during pregnancy. As attitude, rather than knowledge, predicts risk of drinking in a future pregnancy, this presents a challenge for public health campaigns. Alcohol is teratogenic, crosses the placenta, and contributes to a range of physical, developmental, learning and behavioural problems, including fetal alcohol spectrum disorders (FASD). As nearly half of all pregnancies in Australia are unplanned, inadvertent exposure to alcohol is common. Good-quality prevalence data on FASD are lacking in Australia, although alcohol use at "risky" levels is well documented in some disadvantaged communities. In the last decade, clinicians, researchers, governments and non-governmental organizations have shown renewed interest in addressing alcohol use in pregnancy and FASD. This has included a parliamentary inquiry into FASD, provision of targeted funding for FASD, and development of educational materials for health professionals and the general public. Key challenges for the future are to prevent FASD and to offer timely diagnosis and help to children and families living with FASD. The implementation of evidence-based interventions known to decrease access to, and excessive use of, alcohol in our society will aid in the prevention of FASD. The development of national diagnostic tools for screening and diagnosis, and the training of health professionals in the management of FASD, are urgently needed.

Health professionals' knowledge, practice and opinions about fetal alcohol syndrome and alcohol consumption in pregnancy

Is genotype important in predicting the fetal alcohol syndrome?

Foetal alcohol spectrum disorders (FASD) are a set of preventable conditions where the foetus is exposed to alcohol in utero and as a result suffers adverse consequences. To develop a public health strategy related to FASD, it is important to first establish what is known by the public about this condition. This study aimed to assess the current level of knowledge about FASD in the UK general population. A mixed methodology study was conducted using a 17-item questionnaire and focus group sessions. Four focus groups were held with an average of 10 people in each group. Semi-structured questions and thematic analysis of interviews alongside quantitative analysis of the questionnaire data was completed. The research was approved by an National Health service (NHS) research ethical committee. A total of 674 people responded to the questionnaire and a majority (86.7%) had heard about FASD, with most receiving their information from the media (26.2%) or from their work (27.7%). Four broad themes emerged. Overall these were: a general lack of knowledge about the subject; information about the subject needed to be personally relevant; there was a need for further education; and there was a lack of clarity in the current guidance on alcohol use in pregnancy. Currently there appears to be a superficial level of knowledge about FASD in the UK general public. More detailed work in subgroups, such as young women, to identify their specific needs may be necessary before targeted public health and educational interventions can be developed to meet the needs of the general public.

The consumption of alcohol and other substances during pregnancy can impair prenatal development. While scientifically informed public health measures have raised awareness of the risks of harmful prenatal substance exposures, the use of alcohol and other substances during pregnancy continues to rise. The successful dissemination of consistent messaging, health care professional education and training, and universal implementation of clinical interventions may help reduce drinking in pregnancy and prevent fetal alcohol spectrum disorders (FASDs), a constellation of developmental disabilities and birth defects caused by alcohol use during pregnancy. Alcohol screening and brief intervention (alcohol SBI) is an evidence-based preventive practice that enables early identification of excessive drinking and intervention prior to serious consequences. Routine clinical implementation of alcohol SBI has been shown to effectively reduce excessive alcohol consumption among adults, including pregnant people. Many barriers prevent widespread implementation of the practice: a lack of health care professional knowledge of the prevalence and implications of prenatal alcohol exposure, stigma surrounding individuals who use substances potentially harmful to their pregnancy, resistance to public health messages encouraging alcohol avoidance during pregnancy, and discomfort and hesitancy with alcohol SBI procedures among practitioners. The Centers for Disease Control and Prevention (CDC) leads the public health effort to prevent alcohol use during pregnancy and improve identification of and care for children living with FASDs. CDC partners with health systems, health care professional associations, universities, and community-based networks to promote alcohol SBI as an effective but underused preventive health service. This special section consisting of 6 articles including this introductory commentary represents the efforts of 11 CDC projects and their partners to demonstrate the rationale for FASD prevention and intervention, engage health care disciplines to expand prevention messaging and education for providers, develop practical approaches for implementing alcohol SBI in diverse clinical settings, and prevent alcohol use in pregnancy and FASDs.

BackgroundAlcohol use during pregnancy can have a variety of harmful consequences on the fetus. Lifelong effects include growth restriction, characteristic facial anomalies, and neurobehavioral dysfunction. This range of effects is known as fetal alcohol spectrum disorders (FASD). There is no amount, pattern, or timing of alcohol use during pregnancy proven safe for a developing embryo or fetus. Therefore, it is important to screen patients for alcohol use, inform them about alcohol's potential effects during pregnancy, encourage abstinence, and refer for intervention if necessary. However, how and how often nurses and midwives inquire about alcohol drinking during pregnancy or use recommended screening tools and barriers they perceive to alcohol screening has not been well established.MethodsThis survey was sent to about 6,000 American midwives, nurse practitioners, and nurses who provide prenatal care about their knowledge of the effects of prenatal alcohol exposure, the prevalence of alcohol use during pregnancy, and practices for screening patients’ alcohol use. Participants were recruited by e‐mail from the entire membership roster of the American College of Nurse‐Midwives.ResultsThere were 578 valid surveys returned (about 9.6%). Analyses showed that 37.7% of the respondents believe drinking alcohol is safe during at least one trimester of pregnancy. Only 35.2% of respondents reported screening to assess patient alcohol use. Only 23.3% reported using a specific screening tool, and few of those were validated screens recommended for use in pregnant women. Respondents who believe alcohol is safe at some point in pregnancy were significantly less likely to screen their patients.ConclusionsRespondents who reported that pregnancy alcohol use is unsafe felt more prepared to educate and intervene with patients regarding alcohol use during pregnancy and FASD than respondents who reported drinking in pregnancy was safe. Perceived alcohol safety and perceived barriers to screening appeared to influence screening practices. Improving prenatal care provider knowledge about the effects of prenatal alcohol exposure and the availability of valid alcohol screening tools will improve detection of drinking during pregnancy, provide more opportunities for meaningful intervention, and ultimately reduce the incidence of FASD.

Estimating the prevalence of fetal alcohol syndrome in Victoria using routinely collected administrative data