Preventing Alcohol Use During Pregnancy

Project CHOICES

(Changing High-Risk AlcOhol Use and Increasing Contraception Effectiveness Study)

CDC funded three universities to develop brief interventions aimed at preventing alcohol-exposed pregnancies among women of childbearing age in special settings. The selected settings had access to relatively large numbers of women of childbearing age who drank at high-risk levels and did not use contraception effectively.

The grantees, along with the special settings they worked in, were:

• Nova Southeastern University in Ft. Lauderdale, Florida
  • Adult and Pediatric Primary Care Centers in the North Brossard Hospital District of Ft. Lauderdale
  • Recruitment of a cohort of women concerned about problem drinking through media advertisement in the Ft. Lauderdale area
    
    
• University of Texas Health Sciences Center at Houston, School of Public Health in Houston, Texas
  • Harris County Jail
  • Houston Recovery Campus
    
    
• Virginia Commonwealth University, Medical College of Virginia in Richmond, Virginia
  • Gynecology Outpatient Clinic of the Medical College of Virginia
  • South Richmond Health Center

The objectives of the study were to:

• Characterize the women in the special high-risk settings.
• Reduce the rate of alcohol consumption among women who are not using contraception effectively and increase contraception effectiveness among women who do not reduce their alcohol consumption.
• Examine the relationship between selected process variables and study outcomes.

The project was done in three phases: (1) conducting an epidemiologic survey of women in special settings; (2) developing, implementing, and evaluating a behavioral intervention; and (3) measuring the effectiveness of this behavioral intervention further in a scientifically rigorous manner.

Some of the participants received information plus a brief motivational intervention, while others received only information. The brief motivational intervention consisted of four counseling sessions and one contraception consultation and services visit:

• In-depth assessment of alcohol use and contraceptive use patterns.
• Counseling about the consequences of alcohol use during pregnancy.
• Brief advice and counseling for moderate-to-heavy drinkers to reduce intake levels, or referral to community treatment services for alcohol-dependent drinkers.
• Reproductive health education about contraceptive methods, provision of contraceptive services, and client follow-up.

The group that received both information and a brief motivational intervention were twice as likely to be at reduced risk for an alcohol-exposed pregnancy compared to the group that received only information. This shows that a brief motivational intervention can reduce the risk of an alcohol-exposed pregnancy. Project CHOICES has become a model program embraced by researchers and used in other federal initiatives. CDC staff and former CHOICES grantees have provided technical assistance and guidance to those interested in adapting the intervention model for a variety of settings not tested in the original study.

CDC is currently working to package the Project CHOICES intervention (development and pilot testing of a training curriculum, user's manual, and participant workbook) and to develop a marketing and dissemination plan for Project CHOICES products and training.

Related Articles

Motivational interviewing + feedback intervention to reduce alcohol-exposed pregnancy risk among college binge drinkers: determinants and patterns of response
Journal of Behavioral Medicine; 2011; doi: 10.1007/s10865-010-9308-2
Ceperich SD & Ingersoll KS
[Read summary]

A Dual-Focus Motivational Intervention to Reduce the Risk of Alcohol-Exposed Pregnancy
Cognitive and Behavioral Practice; May 2010; 17(2):203-212
Velasquez MM, Ingersoll KS, Sobell MB, Floyd RL, Sobell LC, von Sternberg K
[Read summary]

Preventing Alcohol-Exposed Pregnancies: A Randomized Controlled Trial
American Journal of Preventive Medicine; January 2007; 32(1):1-10
Floyd RL, Sobell M, Velasquez MM, Ingersoll K, Nettleman M, Sobell L, Mullen PD, Ceperich S, von Sternberg K, Bolton B, Johnson K, Skarpness B, Nagaraja J.
[ Read summary]

Motivational Intervention to Reduce Alcohol-Exposed Pregnancies - Florida, Texas, and Virginia, 1997-2001
Morbidity and Mortality Weekly Report; 2003; 52(19):441-444
Centers for Disease Control and Prevention
[Read article]

Reducing the Risk of Alcohol-Exposed Pregnancies: A Study of a Motivational Intervention in Community Settings
Pediatrics; 2003; 111(5):1131-1135
Project CHOICES Intervention Research Group
[Read summary]

Alcohol-Exposed Pregnancy: Characteristics Associated with Risk
American Journal of Preventive Medicine; 2002; 23(3):166-173
Project CHOICES Research Group
[Read summary]

Project CHOICES Plus: A Preconception Approach to Reducing Alcohol & Tobacco-Exposed Pregnancies

The purpose of this study is to determine the efficacy of the Project CHOICES intervention (described above) when combined with screening and referral of smokers to an evidence-based smoking cessation program in reducing both alcohol and tobacco-exposed pregnancies.

Project CHOICES Plus is a randomized controlled trial taking place in two hospitals and 11 community health clinics of the Harris County Hospital District in Harris County, Texas. The study is randomizing groups by clinic site and recruiting women based on their risk for an alcohol-exposed pregnancy. Women are assessed for smoking status and other health behaviors. Women in clinics randomized to the treatment condition will receive a 2-session adaptation of the 4 counseling sessions in the original Project CHOICES. Women in the control group will receive treatment as usual. Outcomes assessed will include average drinks per week over the past month, number of binge drinking episodes in the past month, rates of alcohol abstinence, effective use of contraception, and smoking cessation. Follow-up information will be collected at 3, 6, and 9 months and used to compare the outcomes of the intervention group with the control group.

Implementing Project CHOICES in STD Clinics

Project CHOICES is a brief motivational intervention for reducing alcohol-exposed pregnancies among women who are at high risk for such pregnancies. The purpose of this project is to reduce alcohol-exposed pregnancies by adapting, implementing, and evaluating the Project CHOICES model in sexually transmitted diseases (STD) clinics, integrating this evidence-based intervention into current systems of care.

In 2006, 19 million new cases of STDs occurred; half of these were among people 15 through 24 years of age. Women 18 through 24 years of age are in their peak childbearing years and, according to a national survey in 2005, had the highest levels of binge drinking (21.3%) among all age categories of women 18 through 44 years of age. National data also indicated that the rate of STDs among female heavy drinkers was 7.3%, with rates highest among women 18 through 25 years of age. These data suggest the importance of incorporating alcohol interventions into high-risk settings where other related risk behaviors also are addressed.

Two public health departments have been funded to develop and implement interventions for women of childbearing age within their clinic populations who are at risk for an alcohol-exposed pregnancy. A cross-site evaluation is planned to assess how the Project CHOICES intervention model was integrated into STD clinic processes at each site, to track process and outcome evaluation measures throughout the project period, and to document lessons learned from implementation of these projects.

Funded Sites

Colorado Department of Public Health and Environment in collaboration with the Denver Metro Health Clinic, Denver, Colorado
Baltimore City Health Department in collaboration with Johns Hopkins University, Baltimore, Maryland

Implementing Project CHOICES in Community Health Centers and Family Planning Clinics

Project CHOICES is an extended brief motivational intervention for reducing alcohol-exposed pregnancies among women who are at high risk for such pregnancies. The purpose of these projects is to reduce alcohol-exposed pregnancies by adapting, implementing, and evaluating the Project CHOICES model in community health centers and family planning clinics, integrating this evidence-based intervention into current systems of care.

In 2009, there were approximately 62 million women of childbearing age (15–44 years) in the United States (1).  By 25 years of age, approximately half of these women will have given birth at least once and by 44 years of age, approximately 85% will have done so (2).  Approximately half of all pregnancies in the United States are unplanned (3).  The majority of pregnancies are unrecognized until 4–6 weeks’ gestation and some women will have continued to drink at high levels during these early, critical weeks of fetal development (4). Among nonpregnant women of childbearing age, more than half have reported consuming alcohol, and 12% have reported binge drinking during the past 30 days* (5).  There is mounting evidence that the optimal time for identification and delivery of interventions for many risk factors and health conditions that can contribute to poor pregnancy outcomes is before conception occurs. Community health centers and family planning clinics deliver high-quality services to various populations, including the medically underserved and vulnerable populations. They also offer an important setting for reaching women at risk for an alcohol-exposed pregnancy and a unique opportunity for incorporating alcohol interventions into these systems of care. 

Two organizations have been funded to develop and implement interventions for women of childbearing age who are at risk for an alcohol-exposed pregnancy. A comprehensive evaluation is planned to assess the processes of how the Project CHOICES intervention model has been integrated into community health centers and family planning clinics, to track process and outcome evaluation measures throughout the project period, and to document lessons learned from implementation of these projects.  

Funded Sites

AltaMed Health Services Corporation, Los Angeles, California
New York City Health and Hospitals Corporation, New York, New York

*In these findings, binge drinking was defined as having five or more drinks at one time. More recently, the definition of binge drinking for women has been changed to four or more drinks at one time.

References

1. U.S. Census Bureau, Population Division. Annual Estimates of the Population by Sex and Five-Year Age Groups for the United States: April 1, 2000 to July 1, 2009 (NC-EST2009-01). Release Date: June 2010. Retrieved from http://www.census.gov/popest/national/asrh/NC-EST2009-sa.html
2. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: Final data for 2003. Natl Vital Stat Rep 2005;54:1-116.
3. Finer LB, Zolna MR Unintended pregnancy in the United States: Incidence and disparities, 2006. Contraception 2011, doi:10.1016/j.contraception.2011.07.013
4. Floyd RL, Decoufle P, Hungerford DW. Alcohol use prior to pregnancy recognition. Am J Prev Med 1999;17:101-7.
5. Centers for Disease Control and Prevention. Alcohol use among pregnant and nonpregnant women of childbearing age -- United States, 1991-2005. MMWR Morbidity and Mortality Weekly Report 2009;58(19):529-532.