Toward prevention of alcohol exposed pregnancies: characteristics that relate to ineffective contraception and risky drinking

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Alcohol-exposed pregnancy is a leading cause of preventable birth defects in the United States. This paper describes the motivational patterns that relate to risky drinking and ineffective contraception, two behaviors that can result in
  Toward prevention of alcohol exposed pregnancies:characteristics that relate to ineffective contraceptionand risky drinking Stefania Fabbri   Leah V. Farrell   J. Kim Penberthy   Sherry Dyche Ceperich   Karen S. Ingersoll Received: November 18, 2008/Accepted: April 15, 2009/Published online: May 21, 2009   Springer Science+Business Media, LLC 2009 Abstract  Alcohol-exposed pregnancy is a leading causeof preventable birth defects in the United States. This paperdescribes the motivational patterns that relate to riskydrinking and ineffective contraception, two behaviors thatcan result in alcohol-exposed pregnancy. As part of anintervention study aimed at reducing alcohol-exposedpregnancy 124 women were recruited and reported demo-graphic characteristics, readiness to change, stages of change, drinking, contraception, and sexual behaviorhistory. Our results showed the following.  Drinking : Asignificant positive correlation was found between thenumber of drinks consumed in 90 days and the Importanceto reduce drinking ( r   =  .23,  p  =  .008). A significant neg-ative correlation between number of drinks and confidenceto reduce drinking ( r   = - .39,  p  =  .000) was found aswell. Significant differences were found in the total numberof drinks consumed in 90 days between the five stages of change ( F   =  (4,118), 3.12,  p  =  .01). Women in Prepara-tion reported drinking a significantly higher number of drinks than women in other stages of change.  Contracep-tion : There were significant negative correlations betweenineffective contraception and Importance ( r   = - .38,  p  =  .00), confidence ( r   = - .20,  p  =  .02) and Readiness( r   = - .43,  p  =  .00) to use contraception effectively. Sig-nificant differences in contraception ineffectiveness werefound for women in different stages of change( F   =  (4,115) 8.58,  p  =  .000). Women in Precontemplationreported significantly higher levels of contraception inef-fectiveness compared to women in other stages of change.Results show a clear relationship between higher alcoholconsumption and higher levels of motivation to reducedrinking. In contrast, higher levels of ineffective contra-ception were related to lower levels of motivation to usecontraception effectively. This suggests risky drinking maybe better targeted with brief skills building interventionsand ineffective contraception may require interventionsthat enhance problem awareness and motivation. Keywords  Alcohol exposed pregnancy    Binge drinking   Contraception    Self-efficacy    Stages of change Introduction The problem of alcohol exposed pregnanciesPrenatal alcohol exposure is a leading cause of preventablebirth defects in the United States (Jacobson and Jacobson1994). Alcohol-exposed pregnancy has been associatedwith a spectrum of chronic negative health outcomesincluding learning, emotional regulation, and physicaldisorders known as fetal alcohol spectrum disorders(FASD; Stratton et al. 1996; Sokol et al. 2003; Jones and Smith 1973). At the most severe end of the FASD spec-trum, fetal alcohol syndrome (FAS) is characterized bydistinct facial features, growth abnormalities, and neuro-cognitive deficits that are life-long (Stratton et al. 1996;Jones and Smith 1973). While approximately two of every Dr. Sherry Ceperich is now at the Hunter Holmes McGuire VAMedical Center, Richmond, VA.S. Fabbri ( & )    L. V. Farrell    J. K. Penberthy   S. D. Ceperich    K. S. IngersollUVA Center for Addiction Research and Education,Department of Psychiatry and Neurobehavioral Sciences,University of Virginia, 1670 Discovery Drive, Suite 120,Charlottesville, VA 22911, USAe-mail:  1 3 J Behav Med (2009) 32:443–452DOI 10.1007/s10865-009-9215-6  thousand live births in the United States result in FAS,scientists estimate at least four times more births result inless severe, yet chronic and disabling, developmental andphysical abnormalities along the spectrum, sometimescharacterized as alcohol-related neurobehavioral disorderor alcohol-related birth defects (Sokol et al. 2003; Mattson et al. 1997; May and Gossage 2001). The extent of prenatal alcohol exposureThere is no known safe level of fetal alcohol exposure(Lundsberg et al. 1997; Shaw and Lammer 1999; Sood et al. 2001) yet an estimated 15–50% of fetuses are ex-posed to alcohol in utero (Ebrahim et al. 1999, 1998; Floyd et al. 1999a, b). For 50% of women, pregnancy goes unrecognized until the sixth week, which includes a criticaltime for early brain development (Floyd et al. 1999a, b). While most women do abstain from alcohol followingpregnancy recognition, more than half of pregnant wo-men’s recognition comes after the fetal brain has begun todevelop. Additionally, epidemiological estimates suggestthat approximately 10.1% of women continue to drink evenafter pregnancy is recognized, while 1.9% engage in heavydrinking and binge drinking after pregnancy recognition(Tsai et al. 2007). Overall, an estimated 15% of pregnant women report drinking alcohol while pregnant, either be-fore or after pregnancy recognition (Ebrahim et al. 1999).Risky drinking among women of child bearing ageOne of the nation’s health objectives is to reducedrinking by women of child-bearing age, thus reducingrisk for alcohol-exposed pregnancy (US Department of Health and Human Services 2000). Women of childbearing age who drink at levels defined as ‘‘risky’’ by theNational Institute on Alcohol Abuse and Alcoholism(greater than seven standard-sized drinks per week and/orthree or more standard drinks per occasion) (NationalInstitute on Alcohol Abuse and Alcoholism 2005) are ata higher risk for alcohol-related health problems,including alcohol-exposed pregnancy if they are at risk for pregnancy. Recent estimates of women’s drinkingbehavior suggest approximately 50% of non-pregnantwomen drink alcohol (Ebrahim et al. 1999) while anestimated 13% engage in binge drinking (Tsai et al.2007). Larger proportions of binge drinkers with higherquantity of consumption were found among women of younger ages (18–24 years) or current smokers (Tsaiet al. 2007). A study examining responses to the 2000National Alcohol Survey found that 7% of women of childbearing age drank more than seven drinks weeklyand consumed five or more drinks in one occasion in thepast month (Nayak and Kaskutas 2004). Ineffective contraceptionRisky drinking alone is a necessary but insufficient risk factor for alcohol-exposed pregnancy. The other necessarycomponent is pregnancy. Risk for alcohol-exposed preg-nancy is elevated among women who drink and are at risk for pregnancy, especially if they are not planning orintending to become pregnant. Women are at risk forpregnancy if they are sexually active with a man, use nocontraceptive method, use only ineffective contraceptivemethods, use putatively effective methods erroneously, oruse effective methods intermittently. Unplanned pregnancyrates are high; an estimated 50% of women aged 15 to 44in the United States have experienced at least one un-planned pregnancy and half of all pregnancies are unin-tended (Henshaw 1998). More than 50% of unplanned pregnancies occur to the 7% of women who do not use anycontraception method at all but do not desire pregnancyand another half occur to women who use contraceptionineffectively or intermittently (Brown and Eisenberg 1995; Trussell and Vaughan 1999).Preventing alcohol exposed pregnanciesHelping women increase contraception effectiveness andreduce risky drinking has the potential to reduce the fre-quency of alcohol-exposed pregnancy by preventing un-planned pregnancies and fetal exposure to alcohol shouldpregnancies occur. A few interventions have been found toreduce alcohol-exposed pregnancy risk among communityand college women. One randomized controlled trialsought to reduce women’s risk for alcohol-exposed preg-nancy by targeting reductions in risky drinking. Womenwho received a 15 min, physician-delivered educationalintervention with a contract significantly reduced theirweekly alcohol use and episodes of binge drinking; thesewomen were also almost two times more likely to reducetheir drinking by 20% by the follow-up point. The largestdecreases in alcohol consumption occurred among womenin the experimental group who became pregnant during thefollow-up period, thus reducing alcohol-exposed pregnancyrisk among these women (Manwell et al. 2000). Two other randomized controlled studies were designedto reduce alcohol-exposed pregnancy risk by targeting bothbehaviors: risky drinking and ineffective contraception(Floyd et al. 2007; Ingersoll et al. 2005). These two studies tested the efficacy of brief counseling interventions basedon motivational interviewing (MI) and the stages of change(Floyd et al. 2007; Ingersoll et al. 2005). Community wo- men who were randomly assigned to receive four MIcounseling sessions significantly reduced their risk foralcohol-exposed pregnancy when compared to women as-signed to an information only control condition (Floyd 444 J Behav Med (2009) 32:443–452  1 3  et al. 2007). Similarly, college women were significantlyless likely to drink at risky levels and use ineffectivecontraception if assigned to a one-session MI plus feed-back intervention versus an information control condition(Ingersoll et al. 2005). Very few studies have focused their attention on thecharacteristics of women that place them at risk foralcohol-exposed pregnancy. College drinkers were morelikely to be at risk for an alcohol-exposed pregnancy if they were binge drinkers and used barrier rather thanhormonal contraception, and if their partner initiatedcontraception (Ingersoll et al. 2008). Another study used an epidemiologic survey to characterize the alcohol-exposed pregnancy risk of community women not seekingtreatment. In that study, women with a history of recentdrug use, smoking, inpatient alcohol or drug abusetreatment, inpatient mental health treatment, multiple sexpartners, and recent physical abuse were more likely to beat risk (Project CHOICES Research Group 2002). Thesestudies have identified a few historical and behavioralcharacteristics of women at risk among groups of womennot previously known to be at risk for alcohol-exposedpregnancy. If additional salient characteristics can beidentified among women at risk, interventions could becustomized for maximum effect. Thus, this paper aims todescribe the socio-demographic, behavioral and motiva-tional characteristics related to risky drinking and inef-fective contraception among women found to be at risk for alcohol-exposed pregnancy in order to identify spe-cific therapeutic targets that may further the developmentof effective interventions. Methods ParticipantsThe data used for this investigation came from the baselineassessment of an ongoing randomized control trial, ‘‘Pro- ject EARLY’’, developed to test the efficacy of a one-session motivational interviewing-based intervention toreduce alcohol-exposed pregnancy risk among women of child bearing age (18–44).  Alcohol-exposed pregnancy risk  was defined as having sexual intercourse with a man whileusing contraception ineffectively (no use at all, incorrect orinconsistent use of an effective method or use of an inef-fective method) and drinking at risky levels, defined asconsuming on average more than 7 standard drinks perweek or more than three drinks on one occasion (bingedrinking).  Examples  of ineffective contraception use are:missing two birth control pills in any month without usingan effective backup method, not putting the condom inplace before the insertion of the penis into the vagina or notusing a new condom with each penetration. The use of anineffective method refers to the use of any method thatresults in 20 or more pregnancies in a year per 100 women(e.g.: the rhythm method, withdrawal, use of spermicidesalone etc.)Inclusion criteria were: (1) 18–44-year-old fertile wo-men; (2) not pregnant or planning pregnancy in the next6 months; (3) had vaginal intercourse with a man duringthe previous 90 days with ineffective contraception (seealcohol-exposed pregnancy risk definition above); (4) en-gaged in risky drinking during the previous 90 days (seealcohol-exposed pregnancy risk definition above) and (5)willing to be followed for 6 months.Exclusion criteria were: (1) Untreated Major DepressiveDisorder according to DSM-IV-TR criteria (Caldwell2002); (2) Untreated Opioid Dependence according toDSM-IV-TR criteria (Caldwell 2002). Women with these conditions, if untreated, were excluded in this preliminaryefficacy trial to avoid the inclusion of a population that waslikely to have treatment needs that were beyond the scopeof the study intervention. Such women were referred tocare in the community.Baseline measuresWomen reported demographic characteristics, drinkinghistory, sexual behavior history, contraception history,perceived pregnancy risk, and health behavior history onforms created for the study. To assess daily drinking,vaginal intercourse, contraception method used and effec-tiveness of method used, a Timeline Follow Back calendar-based interview tested previously in Project CHOICES(Floyd et al. 2007) was used. The Timeline Follow Back  approach has been extensively evaluated with clinical andnon clinical populations (Sobell and Sobell 2003) and has been shown to be a generally reliable and valid method forcollecting data on drinking (Sobell and Sobell 1992).Participants were asked to rate how important, confidentand ready they were to make a change in their drinking andto use contraception effectively on a visual analogue scalethat ranged from 0  =  ‘‘Not at all important/confident/ ready’’ to 10  =  ‘‘very important/confident/ready’’ (Impor-tance, confidence and Readiness Ruler) for drinking andcontraception (Rollnick  1998). The ruler is a simple visualanalog scale that was srcinally developed for measuringmotivational levels in smoking cessation (Biener andAbrams 1991), and has subsequently been used in differentsettings such as alcohol (Carey et al. 2002), needle exchange (Blumenthal et al. 2001) and safe sex studies. A recent study (LaBrie et al. 2005b) found that scores on Alcohol and Safer Sex Change Rulers correlated withscores on the Readiness to Change Questionnaire ( r   =  .77for alcohol;  r   =  .77 for safer sex). In both domains, the J Behav Med (2009) 32:443–452 445  1 3  rulers were able to predict behavioral intention just as wellas the Readiness to Change Questionnaire, suggesting thatthe rulers had good concurrent criterion validity. The ruleralso demonstrated good discriminant validity.Participants answered questions from an algorithmabout their stages of change for drinking and contra-ception behavior. Stages of change (precontemplation,contemplation, preparation, action and maintenance) werecategorized according the trans-theoretical model of change (TTM, Prochaska and DiClemente 1982; Civic2000). More specifically, women who were not consid-ering change within the next 6 months were classifiedinto  precontemplation . Participants who intended tochange within the next 6 months were classified into contemplation . Those who were preparing to changewithin the next month were classified into  preparation .Participants who had already changed their behavior andconsistently adhered to behavior change within the pre-vious 6-months were classified as being in the  action stage. Those who had maintained behavior change formore than 6 months were classified as being in the maintenance  stage.ProceduresWomen were recruited for the study through newspaperand online advertisement and flyers posted in two cities inVirginia. Women who responded to the advertisement werethen pre-screened by phone to determine eligibility for thestudy. A research therapist administered the 75 minuteassessment to eligible and consenting women.AnalysesDescriptive statistics characterized the sample demo-graphics, along with drinking, intercourse and contra-ceptive behavior. Pearson correlations were used toidentify relationships between numerical variables suchas total number of drinks, total number of binges, con-traception effectiveness, age, years of education andimportance, confidence and readiness to change. Inde-pendent sample  t  -test and ANOVAs were used to com-pare differences in total number of drinks, total numberof binges and contraception effectiveness across 2 ormore conditions. MANOVAs were conducted to assess if there were differences between different levels of anindependent variable (Alcohol stages of change, Contra-ception stages of change) on a linear combination of three dependent variables (Importance, confidence andReadiness). All statistical tests were two-sided, with a  p value of 0.05 or less considered to indicate statisticalsignificance. All analyses were performed using SPSS16.0 for Windows. Results Half of the women were African American ( n  =  64,51.6%), and single ( n  =  77, 62.1%) and nearly one half were employed either full time or part time ( n  =  57, 46%).The mean age of participants was 28 years (SD  =  7.65),with a mean of 14 yrs of education (SD  =  1.88) (SeeTable 1).Characteristics that relate to risky drinkingParticipants drank a mean of 4 drinks per drinking day andreported 14 binges and 150 drinks over a 90 day period.The mean age of their first drink was 15 years. Participantsreported mean scores of 5.1 for Importance, 5.0 forReadiness and 7.6 for confidence to reduce their drinking(on a 0–10 scale; see Table 1). Most women placedthemselves in the Precontemplation Stage of Change( n  =  51, 42%), followed then by women in Preparation( n  =  33, 27%), Contemplation ( n  =  25, 21%), Action( n  =  9, 7%) and Maintenance ( n  =  4, 3%). There was asignificant positive correlation between age and number of drinks ( r   =  .20,  p  =  .03) but no significant correlationbetween age and number of binges, or education withnumber of drinks or number of binges.There were significant differences in number of drinksbetween different occupational statuses. Women who wereemployed part time drank significantly more than others,including students, full time workers, self-employedworkers or unemployed women ( F  (5,116)  =  4.31,  p  =  .00). The number of drinks and binges did not sig-nificantly differ across different ethnicities.Drinking was related to importance and confidenceratings. Women who drank more reported that it was  moreimportant   to reduce their drinking; more drinks in 90 dayswas positively related to higher importance (Importance,confidence and Readiness Ruler) ( r   =  .23,  p  =  .008) toreduce drinking. In contrast, women who drank more were less confident   in their ability to reduce their drinking; agreater number of drinks was related to lower confidence(Importance, confidence and Readiness Ruler) ( r   = - .39,  p  =  .0001).Drinking differed across women classified in the fivestages of change. Significant differences were found in thetotal number of drinks consumed in 90 days (TimelineFollow Back) between the 5 different stages of change( F   =  (4,118), 3.12,  p  =  .01). Women in the Preparationstage of change reported drinking a significantly highernumber of drinks compared to women in other stages of change. Post hoc analyses performed with Fisher leastsignificant difference test (LSD) showed that women inPreparation drank significantly more (258 drinks) in90 days than women in the Precontemplation (93 drinks) 446 J Behav Med (2009) 32:443–452  1 3  and Action (71 drinks) stages of change, as shown inFig. 1.A MANOVA was conducted to assess if there weredifferences between the five stages of change (independentvariable) in Importance, confidence and Readiness(dependent variables). A MANOVA was chosen becausethe dependent variables were conceptually related and werecorrelated with one another at a low to moderate level( r   ranged from .23 to .56). The assumption of independenceof observation and homogeneity of variance/covariancewere checked and met. A significant difference was foundbetween the five stages of change (Wilks’ K  =  .444, F  (115,304)  =  9.107,  p  =  .00). Examination of the coeffi-cients distinguishing stages of change groups indicated thatImportance and Readiness contributed most to distin-guishing these groups. In particular, both Importance( b  =  38.74,  p  =  .006, multivariate  g 2 =  .06) and Readi-ness ( b  =  41.51,  p  =  .006, multivariate  g 2 =  .06) con-tributed significantly toward discriminating the Preparationgroup from the other stages of change groups, but no othervariables (Importance, confidence or Readiness) signifi-cantly contributed to distinguishing the other stages of change groups from each other. Follow-up univariateANOVAs indicated that both Importance and Readiness,when examined alone, were significantly different forsubjects in different stages of change, ( F  (4,117)  =  32.93,  p  =  .000 and  F  (4,117)  =  15.54,  p  =  .000), respectively.Characteristics that relate to ineffective contraceptionWomen had their first intercourse on average at age 16 andused contraception for the first time on average at age 17.Within the 90 days prior to baseline assessment womenhad intercourse with an average of 1.6 men and usedcontraception ineffectively on 75% of the days they hadintercourse (contraception effectiveness was calculated bydividing the number of days women had intercourse andused contraception effectively by the number of days theyhad intercourse and then multiplying the result by 100).Additionally, women who used no contraception at all re-ported that they believed they had a 68% risk of becomingpregnant within 1 year (see ‘‘perceived pregnancy risk’’ inTable 1). Further, women’s motivation to use contracep-tion effectively was assessed. Participants reported a meanscore of 7.5 for Importance, 7.5 for Readiness and 7.0 forconfidence in the ability to use contraception effectively(see Table 1).Regarding effective contraception use, most womenwere in the Preparation stages of change ( n  =  48, 39%),followed then by women in Contemplation ( n  =  37, 30%),Precontemplation ( n  =  16, 15%), Maintenance ( n  =  13,11%) and Action ( n  =  8, 7%). About half of the womenreported using male condoms (50.8%,  n  =  63), while18.5% ( n  =  23) used the pill, 16.1% ( n  =  20) did not useany form of contraception at all and 8.1% ( n  =  10) usedwithdrawal. The rest used depo-provera injections (1.6%, n  =  2), rhythm (1.6%,  n  =  2), mixed methods (more thanone method used but none considered as the main method)(1.6%,  n  =  2), the vaginal hormonal ring (.8%,  n  =  1) or Table 1  Sociodemographic, drinking, contraception and intercoursebaseline characteristics ( n  =  124)Participants characteristics Frequency %EthnicityAfrican American/black 64 51.6White 44 35.5Other 8 6.9Marital statusSingle 77 62.1Living with partner 22 17.7Married 14 11.3Separated, divorced 11 8.8EmploymentEmployed full time 36 29.9Employed part-time 18 14.5Self employed 3 2.4Student 41 33Unemployed 24 19.4Mean SDAge 28.23 7.66Education 13.88 1.89Drinking characteristicsAge first drink 15.48 2.967Number of drinks/90 days 150.60 235.70Total number of drinking days 32.56 22.03Number of drinks per drinking days 4.20 4.06Average number drinks per week 12.54 19.64Total number of binges 13.76 17.76Importance alcohol (range  =  0–10) a 5.07 3.48Confidence alcohol (range  =  0–10) a 7.59 2.46Readiness alcohol (range  =  0–10) a 5.05 3.40Contraception and intercourse characteristicsAge first intercourse 16.29 2.34Age first use of contraception 16.70 2.39Number of males had intercourse with 1.57 .86Pregnancy perceived risk 68.44 24.21Contraception effectiveness .65 .31Importance (range  =  0–10) a 7.55 2.79Confidence (range  =  0–10) a 7.47 2.79Readiness (range  =  0–10) a 6.99 2.91 a 0  =  lowest levels of importance, confidence and readiness;10  =  maximum levels of importance, confidence and readinessJ Behav Med (2009) 32:443–452 447  1 3
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