This study provides new evidence that brief intervention can reduce alcohol use in post partum women. The statistically significant difference in alcohol use at the 6 month follow-up period suggests a positive treatment effect. As the study was conducted in a diverse sample of practices located in rural, urban and small communities, the findings may be generalizable to other outpatient obstetrical settings. The clinical difference is important and suggests providers can expect a 19% reduction in daily alcohol use, 21% reduction in number of drinking days, and 36% reduction in heavy drinking days among their postpartum patients if they follow the brief intervention protocol tested in the Healthy Moms trial. The findings of this BI trial complement recent studies completed during the pre-pregnancy period (Floyd et al., 2007
) and during pregnancy (Chang et al., 2005
; O'Connor et al. 2007
The findings of this trial have important public health implications. Despite numerous public awareness campaigns and the inclusion of warning labels on alcoholic beverages, fetal alcohol spectrum disorders continue to be a significant cause of disability. FASD is the leading known cause of preventable mental retardation/developmental disabilities in the Western World (Floyd et al., 2007
). The disabilities associated with FASD persist throughout a person's lifetime, and are associated with significant costs to families and society (Stratton et al., 1996
). While the prenatal period is clearly an important time to intervene, by the time a woman realizes that she is pregnant, irreversible damage to the fetus may have already occurred (Floyd et al., 1999
). Preventing alcohol exposure with the next pregnancy may provide the best chance we have to prevent FASD (May et al., 2004
The routine postpartum obstetrical visit is an excellent setting for such an intervention. Other settings for intervention may include the offices of pediatricians, family physicians, public health nurses, or clinics associated with the Women, Infants, and Children Program (Tough et al., 2006
). These represent settings where a mother might accompany her children to appointments. We urge medical providers to adopt alcohol screening as a routine part of care, as many have done for the assessment of postpartum depression and parental smoking practices.
A strong link has been established between interpersonal violence, tobacco use, illicit drug use, depression, and high-risk drinking among women (Flynn et al., 2003
; Certain et al, 2007
; Gilchrist et al., 1996
; Little et al., 1990
). Each of these behaviors is associated with significant health problems for women as well their children and families. While there is limited information on the combined treatment of high-risk drinking and other behaviors, behavioral change is a complex process that often requires multiple lifestyle changes at the same time. The results of this trial suggest health care providers can make a difference. Providers can change alcohol use among new mothers.
Health care systems, payors, policy makers, and society need to acknowledge the potential implications of BI research. We have an effective treatment (BI) that can prevent FASD and other adverse effects related to high-risk drinking among women of childbearing age. We have an evidence-based strategy that can reduce the loss of human potential due to irreversibly damaged nervous systems, as occurs in FASD. It is important to offer alcohol screening and BI to all women of childbearing age. This includes women coming in to see their obstetrician for routine postpartum care.
The strengths of the trial include a diverse sample of postpartum women, recruitment of non treatment seeking research subjects, state of the art research procedures, location of the study in 34 primary care offices, and high follow-up rates. Intention-to-treat procedures were used in the analysis. The recruitment rates were similar to many medication and behavioral trials with 24% (235/1209) of non treatment seeking high-risk drinkers randomized into the trial. One of the strengths of the trial was to screen all patients, not just those seeking alcohol treatment. While the high-risk drinking subjects, who did not meet all of our inclusion criteria, may have responded differently to the BI intervention protocol, our sample does represent a large group of women who did reduce their alcohol use. The effect size one could achieve by intervening with 100% of high-risk post partum women remains unclear. Additional research is needed.
Limitations of the trial include relatively small sample size, short follow-up period, absence of changes in alcohol-related harm outcomes, differential loss to follow-up between groups and reliance on patient self report as the primary outcome. We assume this differential loss to follow-up is related to the research burden of the group assigned to the intervention group (4 provider contacts), resistance to talk further about their drinking, shame about their drinking, reluctance to talk to us by their partners alcohol use or presence of interpersonal partner violence.
Another potential limitation of the study is delivery of the brief intervention protocol by clinic nurses. 90% of the interventions were conducted by clinic nurses. With the increasing use of other providers, such as clinic nurses to deliver routine care, the post partum visit was usually performed by clinic nurses, rather than obstetricians. While there is ample evidence that physicians can successful deliver brief intervention protocols our study was not able to answer the question whether BI can be effectively delivered by obstetricians.
Preventing alcohol-exposed pregnancies and the adverse health effects of alcohol on women is an important public health issue. The findings of this trial support the widespread implementation of alcohol screening and brief intervention during the postpartum period. Inclusion of alcohol screening questions within postpartum electronic medical record templates would facilitate the inclusion of routine screening similar to what has occurred with the addition of routine alcohol screening questions on prenatal forms. Screening all new mothers each year (4 million in 2006), during their postpartum visit or well child care visit, is likely to identify an estimated 480,000 high-risk drinkers in the US alone (Jagodzinski and Fleming, 2007
). All of these women, their children, their families and society could potentially benefit, if health care providers spent a few minutes talking to them about their alcohol use.