Alcohol-Screening Instruments for Pregnant Women
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Alcohol-Screening Instruments
for Pregnant Women
Grace Chang, M.D., M.P.H.
According to new studies, even low levels of prenatal alcohol exposure can negatively affect the
developing fetus, thereby increasing the importance of identifying women who drink during
pregnancy. In response, researchers have developed several simple alcohol-screening
instruments for use with pregnant women. These instruments, which can be administered
quickly and easily, have been evaluated and found to be effective. Because of the potential
adverse consequences of prenatal alcohol exposure, short screening questionnaires are
worthwhile preventive measures when combined with appropriate followup. KEY WORDS: prenatal
alcohol exposure; prenatal diagnosis; alcohol use test; identification and screening for AOD
(alcohol or other drug) use; specificity and sensitivity of measurement; breath alcohol analysis;
AODR (alcohol- or other drug-related) biological markers
S
creening pregnant women for five or more drinks per occasion) by 3.5 drinks per week) demonstrated that
alcohol use has become of increasing pregnant women has increased substan the women who drank more than 3.0
importance, because new research tially, from 0.8 percent in 1991 to 3.5 drinks per week increased significantly
indicates that even low levels of prenatal percent in 1995 (Ebrahim et al. 1998; their risk of first-trimester spontaneous
alcohol exposure can negatively affect Centers for Disease Control and abortion (Windham et al. 1997).
the developing fetus. Adverse effects of Prevention 1997). This rise in the rate Identifying women who drink at
prenatal alcohol exposure can range from of alcohol consumption among pregnant risky levels during pregnancy poses spe
subtle developmental problems, or fetal women coincides with growing evidence cial challenges, however, particularly
alcohol effects, to full-blown fetal alcohol of the negative effects of low-to-moderate because the definition of pregnancy risk
syndrome. In addition, scientists and alcohol consumption during pregnancy. drinking has been refined over time. In
clinicians have found that certain neuro Increasingly sophisticated research addition, screening for any alcohol use
behavioral outcomes associated with has improved scientific and clinical under- during pregnancy is difficult. This arti
prenatal alcohol exposure can persist in standing of the adverse consequences cle discusses the difficulties involved in
the affected person into adolescence of prenatal alcohol exposure. The term screening pregnant women for alcohol
(Sampson et al. 1994) and adulthood “pregnancy risk drinking” (i.e., drink use; details some of the questionnaires,
(Kelly et al. 2000). ing during pregnancy at levels consid or instruments, available to facilitate
Because no universally safe level of ered risky to the fetus) was previously
alcohol consumption during pregnancy defined as the consumption of 1 ounce
has been identified (Stratton et al. 1996), or more of alcohol (i.e., two or more GRACE CHANG, M.D., M.P.H., is an
the U.S. Surgeon General and the drinks) per day (Sokol et al. 1989), but associate professor of psychiatry at Harvard
Secretary of Health and Human Services more recent findings show that even Medical School, Department of Psychiatry,
recommend abstinence both before con lower levels of alcohol consumption can Brigham and Women’s Hospital, Boston,
ception and throughout pregnancy lead to negative pregnancy outcomes Massachusetts.
(Stratton et al. 1996; Ebrahim et al. 1998). (Charness et al. 1994; Wong et al. 1995;
However, approximately 20 percent of Ikonomidou et al. 2000; Jacobson and Preparation of this article was supported
women drink some alcohol during preg Jacobson 1994). A study of more than in part by National Institute on Alcohol
nancy, and the rate of frequent drinking 5,000 pregnant women who consumed Abuse and Alcoholism grants K24–AA–
(i.e., seven or more drinks per week or alcohol moderately (defined as at least 00289 and R01–AA–12548.
204 Alcohol Research & HealthScreening Instruments for Pregnant Women
alcohol screening in this population; and inquiries about drinking patterns before 1996). Progress toward this goal has
briefly describes a few laboratory tests pregnancy confirmation are potentially not yet been reported.
used for detecting alcohol use among more accurate measures of first-trimester In response to the need for increased
pregnant women. drinking (Day et al. 1993). Women are alcohol screening among pregnant women,
also likely to deny or minimize their researchers have developed several alcohol-
drinking during pregnancy out of embar screening instruments specifically for
Complications of rassment (Morrow-Tlucak et al. 1989). use with this population.
Screening Pregnant Even moderate drinkers may underreport
Women for Alcohol Use alcohol consumption during pregnancy
(Verkerk 1992). Data from a sample of Screening Instruments
A key complication in screening preg 361 mothers suggest that women who
nant women for alcohol use arises from report drinking more than 1.3 drinks The screening instruments described in
the fact that the traditional alcohol- per week during pregnancy actually may this section were tested in diverse clini
screening questionnaires—such as the be drinking at levels high enough to cal populations and may help identify
Michigan Alcoholism Screening Test incur risk for alcohol-related birth defects women using alcohol during pregnancy.
(MAST) (Selzer 1971) and the CAGE1 (Jacobson et al. 1991). For example, 53 These instruments vary in that they
(Ewing 1984)—are less effective in percent of the women who reported were designed to detect different levels
identifying drinking problems among drinking more than 1.3 drinks per week of alcohol use and, therefore, differ in
women than among men. This discrep during pregnancy reported higher lev how they define pregnancy risk drinking.
ancy is attributable to the fact that these els of consumption when interviewed In general, a positive screen does not
instruments were developed among men, retrospectively. indicate an alcoholism diagnosis; rather,
who have different patterns of alcohol A third complication is that standard it may signal to a physician or other
consumption and different thresholds questions about quantity and frequency health care practitioner the need to discuss
for problem drinking than women of alcohol consumption are unlikely pregnancy risk drinking with a patient.
(Babor et al. 1989). In addition, these to be helpful when screening pregnant Routine use of screening questionnaires
instruments were developed to detect women for alcohol use. The widely in clinical practices may reduce the
alcohol dependence, which is relatively used American College of Obstetricians stigmatization of asking patients about
uncommon among pregnant women and Gynecologists (ACOG) Antepartum alcohol use and result in more accurate
(Ebrahim et al. 1998). Because of bio Record poses three questions about alco and consistent evaluation.
logical differences between women and hol use: (1) the amount of alcohol con Sensitivity and specificity are two
men, the same quantity of alcohol con sumed per day before pregnancy, (2) the important properties of every screening
sumed over the same time period pro amount of alcohol consumed per day instrument. The sensitivity of a screen
duces higher blood alcohol levels in during pregnancy, and (3) the number ing test refers to the probability that a
women than in men (Graham et al. of years of alcohol use. The Antepartum person who should test positive, does
1998). Women are also more sensitive Record has a fill-in-the-boxes format so (i.e., the sensitivity of a screen for
than men to alcohol-related organ dam- designed to gather standard clinical pregnancy risk drinking is the probabil
age, such as cardiomyopathy and myopa information on obstetric patients. How- ity that a woman who is a risk drinker
thy (Urbano-Marquez et al. 1995; ever, compared with the 13-item Prenatal tests positive). The specificity of a
Hanna et al. 1992). Therefore, alcohol- Alcohol Use Interview, the ACOG screening test is the probability that a
screening-instrument cutoff scores (i.e., Antepartum Record is less successful person who should test negative, does
the values that clinicians use to define in identifying prenatal alcohol use. so (i.e., the probability that a woman
a positive result from a screening instru Researchers suggest that the difference who is not a risk drinker tests negative)
ment) most likely need to be set differ in findings between the two instruments (Rosner 1990).
ently for men and women and particu may be attributable to the format of
larly for pregnant women (Bradley et the ACOG Antepartum Record and its
al. 1998). lack of guiding questions: the ACOG
The T-ACE
A second complication faced by instrument requires a skilled interviewer The T-ACE was the first validated sen
researchers is that many women alter their in order to elicit accurate responses about sitive screen for risk drinking (defined
alcohol consumption once they learn drinking during pregnancy (Budd et al. as alcohol consumption of 1 ounce or
that they are pregnant. Consequently, 2000). more per day) developed for use in
A final complication is that obstetri obstetric-gynecologic practices (Sokol
1
cians inconsistently screen their patients et al. 1989). An obstetrician developed
The CAGE screening instrument (Ewing 1984) consists
of four questions: (1) Have you ever felt you should Cut
for alcohol use during pregnancy. One the T-ACE after observing that asking
down on your drinking?, (2) Have people Annoyed you by goal of Healthy People 2000 was to patients about their tolerance to the
criticizing your drinking?, (3) Have you ever felt bad or increase obstetricians’ rate of screening intoxicating effects of alcohol did not
Guilty about your drinking?, and (4) Have you ever had a
drink first thing in the morning to steady your nerves or to for alcohol use to 75 percent, from the trigger denial. The “socially correct”
get rid of a hangover (Eye opener)? 1987 rate of 34 percent (Stratton et al. answer is not known (patients do not
Vol. 25, No. 3, 2001 205feel stigmatized to answer honestly), and make you feel high?” The T-ACE was the AUDIT and SMAST independently
tolerance reflects a pattern of drinking. not administered as an independent as well as reviewed the participant’s
The four T-ACE questions (see T instrument; instead, both the sensitivity medical record. The three criteria used
ACE textbox) take less than 1 minute and specificity of the T-ACE were cal to evaluate the T-ACE, AUDIT, SMAST,
to ask. The T-ACE is positive with a culated from the subjects’ responses to and medical record were as follows: (1)
score of 2 or more points. One point is the tolerance question as well as to the alcohol abuse or dependence diagnoses
given for each affirmative answer to the annoyed, cut-down, and eye-opener as defined according to the Diagnostic
A, C, or E questions. Two points are questions from the CAGE questionnaire. and Statistical Manual of Mental Disorders,
given when a pregnant woman reports The T-ACE proved to be superior to Third Edition, Revised (DSM-III-R)
that more than two drinks are necessary both the MAST and CAGE in identi (American Psychiatric Association 1987),
for her to feel “high” or experience the fying pregnancy risk drinking (i.e., which the subject could meet at any
intoxicating effects of alcohol. defined as alcohol consumption of more point in her lifetime; (2) risk drinking,
Researchers initially evaluated the than 1 ounce daily). Table 1 summa defined as having more than two drinks
T-ACE in a sample of 971 African- rizes the study’s findings. per drinking day before pregnancy; and
American women attending an inner-city We subsequently tested the T-ACE (3) current drinking (i.e., any alcohol
antenatal clinic. The researchers admin as a self-administered, independent consumption during pregnancy).
istered both the MAST and CAGE as screening tool embedded in a health- Table 2 summarizes the sensitivity
well as asked the T-ACE tolerance ques habits survey with questions about smok and specificity of the T-ACE, AUDIT,
tion, “How many drinks does it take to ing, stress, weight, and dietary habits in SMAST, and medical record for the
a more socially and ethnically diverse three criteria. In addition, sensitivity
obstetric population—350 women ini and specificity for varying cut-off scores
T-ACE tiating prenatal care at the Brigham and for the T-ACE and AUDIT are listed
Women’s Hospital in Boston, Massa (e.g., in response to the tolerance question
chusetts (Chang et al. 1998). in the T-ACE, “more than 2 drinks”
T Tolerance: How many drinks We compared the sensitivity and would be a positive response in one
does it take to make you feel specificity of the T-ACE with the sensi scoring method and “2 or more drinks”
high? tivity and specificity of three other pop would be a positive response when
ular methods of screening for alcohol using a different scoring method). With
A Have people Annoyed you by use in other clinical settings: (1) the “tolerance” defined as “2 or more drinks
criticizing your drinking? Alcohol Use Disorders Identification to feel intoxicated,” the T-ACE was the
Test (AUDIT) (Babor et al. 1992), (2) most sensitive instrument to detect cur-
C Have you ever felt you ought the Short Michigan Alcoholism Screening rent alcohol consumption, risk drink
to Cut down on your drinking? Test (SMAST) (Selzer et al. 1975), and ing, and lifetime DSM-III-R alcohol
(3) a review of the patient’s medical diagnoses. However, it was also the
E Eye opener: Have you ever record. Researchers gave each participant least specific.
had a drink first thing in the
morning to steady your nerves
or get rid of a hangover? Table 1 Comparison of the T-ACE, CAGE, and MAST in Identifying Pregnancy
Risk Drinking
The T-ACE is used to screen for
pregnancy risk drinking, defined Screening for Pregnancy Risk Drinking*
here as the consumption of
1 ounce or more of alcohol per
Positive Test Score Sensitivity Specificity
day while pregnant. Scores are Instrument (points accrued) (%) (%)
calculated as follows: a reply of
“More than two drinks” to ques
tion T is considered a positive T-ACE (> 2) 69 89
response and scores 2 points, and CAGE (> 2) 38 92
MAST (> 5) 36 96
an affirmative answer to question
A, C, or E scores 1 point, respec
tively. A total score of 2 or more
MAST = Michigan Alcoholism Screening Test.
points on the T-ACE indicates a *Pregnancy risk drinking is defined as the consumption of 1 ounce or more of alcohol per day during pregnancy.
positive outcome for pregnancy NOTE: The sensitivity of a screening test is the probability that a person who should test positive, does so (i.e.,
risk drinking. the sensitivity of a screen for pregnancy risk drinking is the probability that a woman who is a risk drinker tests
positive). The specificity of a screening test is the probability that a person who should test negative, does so
(i.e., the probability that a woman who is not a risk drinker tests negative) (Rosner 1990).
SOURCE: Sokol et al. 1989.
SOURCE: Sokol et al. 1989.
206 Alcohol Research & HealthScreening Instruments for Pregnant Women
The ideal screening test would be in diverse obstetric populations. The patients at two primary health care cen
both highly sensitive and highly spe questions are easy to both remember ters; and (3) the general population of
cific; however, any given test usually and score and can be asked by an obste the Buffalo, New York, metropolitan area
has a trade off. Screeners typically give trician or nurse in 1 minute. Women (Chan et al. 1993). Subsequent evaluation
priority to sensitivity if it is important waiting for their prenatal appointments, of the TWEAK has revealed its promise
to identify a condition, even if more for example, could be asked to complete as a screening tool for identifying preg
false positives are subsequently identi the T-ACE as part of a routine patient nant women who are at-risk drinkers,
fied. However, if insufficient resources questionnaire to be reviewed during defined as those consuming 1 ounce of
are available to evaluate all patients who the visit. alcohol or more daily (Russell et al. 1994).
screen positive, then specificity may be The TWEAK is scored on a 7-point
considered more important (Russell scale. On the tolerance question, 2 points
1994). Thus, the T-ACE, with a posi
The TWEAK
are given if a woman reports that she
tive response to the tolerance question The TWEAK is a five-item screening can consume more than five drinks
defined as “more than 2 drinks,” offers tool that includes questions from the without falling asleep or passing out. A
the best balance of sensitivity and MAST, CAGE, and T-ACE (see TWEAK positive response to the worry question
specificity. textbox). The TWEAK is designed to yields 2 points, and positive responses
The T-ACE is a valuable and efficient detect alcoholism or heavy drinking to the last three questions yield 1 point
tool for identifying alcohol use among and was first tested in three male and each. A woman who has a total score of
pregnant women; in addition, it demon female samples randomly selected from 2 or more points is likely to be an at-
strates acceptability and accuracy in three groups: (1) alcoholics in treat risk drinker.
identifying a range of alcohol-use levels ment at a county medical center; (2) Like the T-ACE, the TWEAK asks
about tolerance to the effects of alcohol.
In one study of 4,743 African-American
Table 2 Sensitivity and Specificity of the T-ACE, AUDIT, SMAST, women of low socioeconomic status
and Medical Record who were given the MAST, the CAGE,
and the T-ACE tolerance question, the
Criterion Sensitivity* Specificity** calculated sensitivity and specificity of
Standard Instrument (%) (%) the TWEAK were 79 percent and 83
percent, respectively, in contrast to the
DSM-III-R T-ACE (tolerance > 2) 87.8 36.6 calculated 70-percent sensitivity and
lifetime alcohol T-ACE (tolerance > 2) 60.0 66.4
85-percent specificity of the T-ACE.
diagnosis AUDIT (> 11) 7.0 99.6
AUDIT (> 10) 11.0 99.0
Periconceptional risk drinking, defined
AUDIT (> 8) 22.6 97.4 as 1 ounce or more of alcohol consump
SMAST 14.8 97.9 tion per day or 14 drinks per week dur
Medical record 15.6 93.6 ing a typical week before pregnancy
(Russell et al. 1994), was the criterion
Risk drinking T-ACE (tolerance > 2) 92.4 37.6 standard (i.e., this was the level of
(two drinks per day T-ACE (tolerance > 2) 74.3 71.4 drinking that the instruments were try
before pregnancy) SMAST 11.4 95.9
ing to detect). The ability to generalize
Medical record 6.7 89.4
these findings is limited. This is attribut
Current alcohol T-ACE (tolerance > 2) 89.2 37.8 able to the homogenous makeup of the
consumption T-ACE (tolerance > 2) 60.0 66.9 sample, the fact that neither the T-ACE
(while pregnant) AUDIT (> 11) 3.3 97.8 nor the TWEAK were administered
AUDIT (> 10) 6.7 96.9 as independent instruments, and the
AUDIT (> 8) 15.0 93.9 definition of periconceptional risk
SMAST 7.5 94.3 drinking, which other researchers have
Medical record 20.0 96.1 subsequently updated to 0.5 ounces of
SMAST = Short Michigan Alcoholism Screening Test.
alcohol per day (Hankin and Sokol 1995).
*Sensitivity is the probability that a person who should test positive, does so (Rosner 1990). The TWEAK does not appear to
**Specificity is the probability that a person who should test negative, does so (Rosner 1990). offer any significant advantages over
NOTE: The sensitivity and specificity for varying cutoff scores for the T-ACE and AUDIT are listed (e.g., in
response to the tolerance question in the T-ACE, “more than two drinks” would be a positive response in one
the T-ACE. Most studies investigating
scoring method and “two or more drinks” would be a positive response under a different scoring method). With the TWEAK’s performance have relied
tolerance defined as two or more drinks to feel intoxicated, the T-ACE was the most sensitive instrument to
detect current alcohol consumption, risk drinking, and lifetime DSM-III-R alcohol diagnoses. However, it was
on a definition of risk drinking that
also the least specific. does not reflect more current research.
SOURCE: Chang et al. 1998. Nonetheless, it offers another option
for clinicians.
Vol. 25, No. 3, 2001 207Other Screening of drinking by most pregnant women 2000), brief interventions (i.e., short
Questionnaires (i.e., it is unlikely that pregnant women counseling sessions) may be especially
will consume alcohol right before their effective in this population. Given the
Research has not established the utility obstetric appointment) (Testa and potential adverse consequences of pre-
of other screening questionnaires—the Reifman 1996; Lundberg et al. 1997; natal alcohol exposure, short screening
CAGE, SMAST, AUDIT, and Prenatal Strano-Rossi 1999). However, recent questionnaires are worthwhile preven
Alcohol Use Interview—for pregnant research has demonstrated the potential
tive measures. ■
women. The CAGE and the SMAST value of maternal blood markers for
are popular self-report measures of detecting levels of alcohol use during
alcoholism and are well studied in alco pregnancy that may result in overt
holic and nonalcoholic subjects and alcohol-related deficits in newborns.
among males (Bradley et al. 1998). The However, the most significant and most TWEAK
AUDIT is a 10-item questionnaire that common result of prenatal alcohol expo-
identifies harmful and hazardous drink sure, neurobehavioral dysfunction, is
ing during the past year and has been not an outcome recognized in the new-
T Tolerance: How many
drinks can you hold?
validated in six countries (Cherpitel 1995). born period. Therefore, research has yet
The Prenatal Alcohol Use Interview is to establish the relevance of these blood
a 13-item questionnaire that has been markers to the more common fetal alco
W Have close friends or rela
tives Worried or com
tested in a sample of 56 women thus far hol effects (Jones and Chambers 1998;
plained about your drink
and requires further evaluation (Budd Stoller et al. 1998). (See the article by
ing in the past year?
et al. 2000). Bearer on pp. xx-xx of this issue for more
Two large studies of disadvantaged, information on potential biomarkers to
minority, obstetric patients (Hankin and detect alcohol use during pregnancy.)
E Eye Opener: Do you
sometimes take a drink in
Sokol 1995; Russell et al. 1996) reported
the morning when you
that the calculated sensitivity and speci
get up?
ficity of the T-ACE and TWEAK were Summary
superior to the CAGE in identifying
risk drinking (defined as 1 ounce or Simple screening questionnaires, such
A Amnesia: Has a friend or
family member ever told
more of alcohol consumption per day). as the T-ACE, provide valuable tools
you about things you said
In another study, we gave the SMAST, for identifying women who are using
or did while you were
AUDIT, and T-ACE questions inde alcohol during pregnancy. The T-ACE
drinking that you could
pendently to 350 pregnant women has been shown to identify any alcohol
not remember?
(Chang et al. 1998) and calculated how consumption during pregnancy as well
well each of the three instruments could as higher amounts of drinking. Research
predict lifetime DSM-III-R alcohol diag has demonstrated that any alcohol con
K(C) Do you sometimes feel
the need to Cut down on
noses and any drinking during pregnancy. sumption during pregnancy increases
your drinking?
The SMAST did not perform better the risk of continued drinking during
than chance as a predictor for either of pregnancy (Chang et al. 1999).
The TWEAK is used to screen
the two drinking categories. Although The T-ACE is administered easily.
for pregnancy risk drinking,
the AUDIT had good predictive abil A clinician may either ask the T-ACE
defined here as the consumption
ity, the definition of a “positive” score questions directly or request that the
of 1 ounce or more of alcohol
on the AUDIT for drinking pregnant patient complete the questionnaire while
per day while pregnant. Scores
women remains to be identified and waiting for her appointment. The T
are calculated as follows: A positive
confirmed through further research. ACE has been tested and demonstrated
response to question T on
to be acceptable and effective in both
Tolerance (i.e., consumption of
formats.
more than five drinks) or question
Laboratory Tests for A positive screen is not an indict
W on Worry yields 2 points
Detecting Alcohol Use ment. Rather, it is an opportunity for
each; an affirmative reply to
the clinician and patient to discuss pre-
question E, A, or K scores 1 point
Although the central focus of this arti natal alcohol exposure. The discussion
each. A total score of 2 or more
cle is on screening questionnaires, other may lead the clinician to refer the patient
points on the TWEAK indicates
methods of detecting alcohol use dur for a diagnostic assessment. Or the
a positive outcome for pregnancy
ing pregnancy deserve some comment. clinician may offer a brief intervention
risk drinking.
Use of breath analysis or urinalysis in if the patient does not have a severe
pregnant patients is not likely to be fea alcohol problem. Because most preg SOURCE: Chan et al. 1993.
sible or acceptable, given the rapid nant women are highly motivated to
metabolism of alcohol and the pattern change their behaviors (Hankin et al.
208 Alcohol Research & HealthScreening Instruments for Pregnant Women
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