Alcohol Use and Pregnancy: Improving Identification GRACE CHANG, MD, MPH, LOUISE WILKINS-HAUG, MD, PhD, SUSAN BERMAN, MD, MBA, MARGARET ANN GOETZ, MPH, HEIDI BEHR, AND ASHLYN HILEY Objective: To test the effectiveness of a four-item prenatal- alcohol-use, self-administered screening questionnaire that asks about tolerance to alcohol, being annoyed by other’s comments about drinking, attempts to cut down, and having a drink first thing in the morning (“eye-opener”) (T-ACE) in an ethnically and socioeconomically diverse sample. Methods: Two hundred fifty T-ACE–positive and 100 T- ACE–negative women completed a comprehensive assess- ment of their alcohol use after initiating prenatal care at the Brigham and Women’s Hospital in Boston, Massachusetts. This comprehensive assessment, which included the Alco- hol Use Disorders Identification Test and the Short Michi- gan Alcoholism Screening Test as comparisons to the T- ACE, generated three criterion standards: Diagnostic and Statistical Manual of Mental Disorders, Third Ed., Revised (DSM-III-R), lifetime alcohol diagnoses, risk drinking (reg- ularly having more than one fluid ounce of alcohol per drinking day before pregnancy), and current drinking. Results: T-ACE–positive pregnant women were more likely than T-ACE–negative women to satisfy DSM-III-R criteria for lifetime alcohol diagnoses (40% versus 14%, P < .001) and risk drinking (39% versus 8%, P < .001) and to have current alcohol consumption (43% versus 13%, P < .001). In contrast, obstetric staff members documented only 33 (9%) women as using alcohol at any time, even though nearly all subjects (96%) were asked about drinking upon initiation of prenatal care. Conclusion: The T-ACE was the most sensitive screen for lifetime alcohol diagnoses, risk drinking, and current alco- hol consumption. It outperformed obstetric staff assessment of any alcohol use by pregnant women enrolled in the study. (Obstet Gynecol 1998;91:892– 8. © 1998 by The American College of Obstetricians and Gynecologists.) Approximately 20% of women will drink some alcohol during pregnancy, even though no universally safe level of alcohol consumption has been identified. 1 Drinking alcohol while pregnant can result in defects ranging from subtle developmental problems to fetal alcohol syndrome. 2 Risk for negative neonatal out- comes may occur with as little as one drink a day. 3 A recent study 4 by the Centers for Disease Control and Prevention reveals that rates of frequent drinking (defined as more than seven drinks per week or more than five drinks per occasion) by pregnant women increased from 0.8% in 1991 to 3.5% in 1995. Abstinence before conception and throughout pregnancy is the recommendation of the United States Surgeon General and the Secretary of Health and Human Services. 1,4 Healthy People 2000 goals established by the Depart- ment of Health and Human Services include increasing the 79% abstinence rate of 1987 to 95% and increasing the rate of screening for alcohol use by obstetricians- gynecologists from 34% in 1987 to 75%. 1 However, the detection of pregnancy risk drinking, defined as an ounce or more of alcohol a day, is difficult in the absence of a laboratory test and in the presence of possible patient denial. 5 Many women will alter their alcohol consumption once their pregnancy is known, so that inquiries about drinking patterns before pregnancy confirmation are potentially more accurate measures of first-trimester drinking and predict drinking levels dur- ing pregnancy. Even moderate drinkers may under- report their consumption during pregnancy. 6 Because they were developed among male alcoholics, traditional alcohol screening instruments are less effective in iden- tifying heavy drinking. 7 A four-item screening questionnaire, which asks about tolerance to alcohol, being annoyed by other’s comments about drinking, attempts to cut down, and having a drink first thing in the morning (“eye-opener”) From Brigham and Women’s Hospital and the Departments of Psychiatry and Obstetrics and Gynecology, Harvard Medical School, Boston, Massachusetts; and the Department of Obstetrics and Gynecol- ogy, Hutzel Hospital, Wayne State University, Detroit, Michigan. This study was supported by RO1 AA 9670 from the National Institute on Alcohol Abuse and Alcoholism (Dr. Chang). 892 0029-7844/98/$19.00 Obstetrics & Gynecology PII S0029-7844(98)00088-X