Obstetrics & Gynecology Track the topics, authors and articles important to you
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Obstetrics & Gynecology 2000;95:756-763
© 2000 by The American College of Obstetricians and Gynecologists
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by DIEKMAN, S. T.
Right arrow Articles by SOKOL, R. J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by DIEKMAN, S. T.
Right arrow Articles by SOKOL, R. J.

ORIGINAL RESEARCH

A Survey of Obstetrician–Gynecologists on Their Patients’ Alcohol Use During Pregnancy

SHANE T. DIEKMAN, MPH, R. LOUISE FLOYD, RN, DSN, PIERRE DÉCOUFLÉ, ScD, JAY SCHULKIN, PhD, SHAHUL H. EBRAHIM, MD, MSc, Dr med and ROBERT J. SOKOL, MD

From the National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia; Department of Research, American College of Obstetricians and Gynecologists, Washington, DC; and Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan.

Address reprint requests to: Louise Floyd, RN, DSN National Center for Environmental Health CDCP, Fetal Alcohol Syndrome Branch 4770 Buford Highway NE, MS-F49 Atlanta, GA 30341-3724


   Abstract
Top
Abstract
Materials and Methods
 Results
 Discussion
 References
 
Objective: To examine knowledge, attitudes, current clinical practices, and educational needs of obstetrician–gynecologists regarding patients’ alcohol use during pregnancy.

Methods: A 20-item, self-administered questionnaire on patients’ prenatal alcohol use was sent to 1000 active ACOG fellows. Responses were analyzed using univariate and multivariate statistical techniques.

Results: Of the 60% of the obstetrician–gynecologists who responded to the survey, 97% reported asking their pregnant patients about alcohol use. When a patient reports alcohol use, most respondents reported that they always discuss adverse effects and always advise abstinence. One fifth of the respondents (20%) reported abstinence to be the safest way to avoid all four of the adverse pregnancy outcomes cited (ie, spontaneous abortion, central nervous system impairment, birth defects, and fetal alcohol syndrome); 13% were unsure about levels associated with all of the adverse outcomes; and 4% reported that consumption of eight or more drinks per week did not pose a risk for any of the four adverse outcomes. The two resources that respondents said they needed most to improve alcohol-use assessment were information on thresholds for adverse reproductive outcomes (83%) and referral resources for patients with alcohol problems (63%).

Conclusion: Efforts should be made to provide practicing obstetrician–gynecologists with updates on the adverse effects of alcohol use by pregnant women and with effective methods for screening and counseling women who report alcohol use during pregnancy.

Recent reports concerning increased rates of prenatal alcohol use among pregnant women have indicated the need to assess the role of health care providers in identifying and counseling pregnant women who consume alcohol and in referring them to appropriate alcohol treatment services.1,2 The advice women receive from physicians and other health care professionals is an important factor in their decision to decrease their substance use.3 Obstetrician–gynecologists are major providers of health care to both pregnant women and to women planning to become pregnant.4 In 1993, in the United States, women aged 15–44 made over 52 million visits to obstetrician–gynecologists.5 With over 4 million deliveries a year, and with several visits for each pregnancy, a substantial number of those contacts were prenatal: these prenatal visits provide a unique opportunity for clinical intervention because approximately 760,000 of the 4 million women who give birth each year drink alcohol, 820,000 smoke cigarettes, and 500,000 use illicit drugs during pregnancy.6 Previous research has shown that physicians’ beliefs, attitudes, and perceptions about a health problem can predispose them either to pursue or to avoid identifying, counseling, and managing that health problem.7

In 1994, ACOG and the American Academy of Pediatrics released a joint statement advising clinicians that pregnant women should be questioned at their first prenatal visit about past and present alcohol use.8 In a separate report, ACOG recommended that clinicians use the T-ACE9 (Tolerance-Annoyed, Cut down, Eye opener) to screen pregnant women for alcohol use.10 Our purpose in conducting this study was to assess, from a national perspective, the knowledge, attitudes, current clinical practices, and educational needs of obstetrician–gynecologists with respect to their patients’ alcohol use during pregnancy.


   Materials and Methods
Top
Abstract
 Materials and Methods
Results
 Discussion
 References
 
This survey was conducted by ACOG; a questionnaire was mailed to a sample of obstetrician–gynecologists who were members of ACOG and actively engaged in providing obstetric services at the time of the survey. The primary sampling frame for the survey was the active membership file of ACOG. A systematic, random sample of 800 physicians was drawn from this population. In addition, questionnaires were sent to the 200 members of the Collaborative Ambulatory Research Network, which consists of ACOG members who volunteer to participate in periodic, topical surveys of interest to ACOG. From 1000 physicians sampled, 604 (60%) completed questionnaires were returned after the first mailing and a follow-up mailing. The demographics of nonrespondents are not known. The questionnaire consisted of 20 items, predominantly multiple-choice and four-point Likert scale items. The survey included questions concerning obstetrician–gynecologists’ alcohol screening practices; their opinions about thresholds at which prenatal alcohol use causes specific adverse pregnancy outcomes; and their counseling and referral practices for patients with moderate or heavy alcohol use. The survey also asked questions about the perceived barriers to alcohol assessment and perceived needs for alcohol assessment training. In the questionnaire, moderate alcohol drinking was defined as an average of three to 13 drinks per week and heavy drinking was defined as an average of 14 or more drinks per week or at least five or more drinks on any one occasion. Demographic and workplace questions followed the alcohol questions.

Descriptive statistics were used to describe and characterize the knowledge, attitudes, clinical practices, and educational needs of respondents participating in the survey. Missing or invalid responses for a particular question were excluded from the analysis of that question. For some analyses, multiple-choice and four-point Likert scale responses were collapsed to yield two categories. To determine the percentage of clinicians who indicated some barriers to alcohol use assessment in clinical practice compared with those who indicated no barriers, the percentages were determined by pooling the responses: sometimes, usually, and always. Differences in stratified categoric data were assessed using {chi}2 tests. A P value <.05 was considered statistically significant in all analyses.

To address variations in responses to selected questions by gender, we obtained prevalence rate ratios that were adjusted for age using standard statistical techniques. Similarly, to address variations in responses by year of medical school graduation, we computed prevalence rate ratios comparing obstetrician–gynecologists who graduated before 1973 and those who graduated between 1973 and 1989 with those who graduated after 1990; we also controlled for gender. The first graduation category (before 1973) was established to coincide with the period before the first documented clinical reports about fetal alcohol syndrome.11 The second category (1973–1989) included the year 1981, in which the first official advisory12 recommending abstinence from alcohol use by women who were pregnant or planning to become pregnant was issued; after that advisory professional organizations and medical education institutions began to incorporate information about prenatal alcohol use into medical school curricula. The third category (1990 and later) coincided with the period during which warning labels began to appear on alcohol products,13 as well as with official health advisories that were issued as part of the United States Department of Agriculture and Health and Human Services’ Dietary Guidelines for Americans.14,15


   Results
Top
Abstract
 Materials and Methods
 Results
Discussion
 References
 
Overall, 60% of the respondents were male. The respondents’ ages ranged from 27 to 89 years, with a median age of 41 years. Male respondents tended to be older than female respondents (47 compared with 39 years). Forty-four percent of the respondents were 27–39 years in age, 45% were 40–59, and 11% were 60 or older. The age and gender distributions of survey respondents were similar to those of ACOG members overall. Year of medical school graduation ranged from 1930 to 1997, with a median of 1984. Twenty-five percent of the respondents graduated from medical school before 1973, 48% between 1973 and 1989, and 27% after 1989. The largest subgroup of respondents (51%) were in a group private practice; 21% were in solo private practice; 20% were salaried employees of either a managed care organization, university or medical school, or state or federal government; and 8% were other types, such as active duty military, salaried at community health center/hospital, and still in residency. Respondents were asked to report the number of deliveries each year at their prenatal practice: 23% reported fewer than 100 deliveries per year, 45% reported 101–250 deliveries, and 32% reported over 250 deliveries.

Nearly all respondents reported that they ask all their pregnant patients about alcohol use (Table 1Go). Forty-eight percent of respondents obtain information about prenatal alcohol use themselves, 41% have nonphysician staff obtain it, and 19% have their patients fill out a self-administered questionnaire. Almost one quarter of respondents reported using a standardized alcohol screening questionnaire, and most of those (64%, 88 of 137) used the CAGE16 (a mnemonic for Cut down, Annoyed, Guilty, Eye opener).


View this table:
[in this window]
[in a new window]
  		Table 1. Assessment and Management Practices of Obstetrician–Gynecologists Regarding Patient Alcohol Use During Pregnancy
 
In the survey, the respondents were asked to indicate the number of drinks per week a pregnant woman could consume without risk for each of the four outcomes listed in Table 2Go. In looking at responses overall to all four outcomes, 20% reported that pregnant women should abstain from alcohol, 13% were unsure about levels associated with the adverse outcomes, and 4% reported that consumption of eight or more drinks per week did not pose a risk for any of the four adverse outcomes. When the responses were analyzed separately for each of the four outcomes, over one quarter of the respondents indicated that pregnant women should abstain from alcohol use (Table 2Go). The percentage of respondents who were unsure about the number of drinks that is harmful to pregnancy was lower for central nervous system (CNS) impairment and fetal alcohol syndrome than for birth defects or spontaneous abortion (Table 2Go). Mean and median number of drinks that respondents believed a woman can consume without a risk was lower for spontaneous abortion and CNS impairment than for birth defects or fetal alcohol syndrome (Table 2Go).


View this table:
[in this window]
[in a new window]
  		Table 2. Number of Drinks Respondents Believe Pregnant Women Can Consume Without Risk of Selected Adverse Pregnancy Outcomes
 
When asked about the management of pregnant women who report moderate alcohol use, the vast majority of respondents reported discussing adverse effects and advising their patients to abstain (Table 1Go). We found some variations in clinical management related to whether a woman reports moderate or heavy alcohol use. Obstetrician–gynecologists were slightly more likely (P > .05) to discuss adverse effects or advise abstinence or reduction if a pregnant woman reports heavy alcohol use than if she reports moderate use (Table 1Go). Respondents were almost three times more likely to refer a patient for treatment if she reported heavy alcohol use than if she reported moderate alcohol use (61% compared with 21%, P = .001). One half of the respondents indicated that they advise and educate all their pregnant patients about the consequences of drinking during pregnancy, whereas most of the rest do so only for current or suspected drinkers or for those with risk factors associated with drinking during pregnancy (eg, smoking). Nine out of ten respondents reported that they always ask further questions about the extent of drinking when alcohol use is reported.

Thirty percent of respondents indicated that they felt very prepared to assess their patients’ alcohol use, 66% indicated that they felt somewhat prepared, and 4% indicated that they felt unprepared. Most indicated that lack of time, patient sensitivity, and the need for additional training to enhance their ascertainment skills were all barriers to assessment of their patients’ alcohol use (Table 3Go). Most respondents reported the need for increased availability of information about thresholds for adverse reproductive outcomes and referral sources for patients with alcohol problems (Table 3Go). Almost half (44%) of the respondents also reported the need for training and consultation in assessment and counseling, and for reimbursement by insurance and providers for screening and assessment (Table 3Go).


View this table:
[in this window]
[in a new window]
  		Table 3. Barriers and Needs Affecting Assessment and Management of Patients’ Alcohol Use During Pregnancy
 
When asked whether they received adequate medical school training regarding alcohol use by pregnant women, 27% of respondents said their training was inadequate, 35% said it was adequate, 28% said it was very good, and 10% said it was outstanding (data not shown in tables). The reported adequacy of that training correlated significantly with the respondents’ year of medical school graduation, with a higher rating being given more often by the most recent graduates (P = .001). Ninety-three percent of respondents who graduated from medical school after 1989 reported adequate or better medical school training regarding alcohol use by pregnant women, compared with 81% among those who graduated between 1973 and 1989, and 40% among those who graduated before 1973.

The proportion of respondents who reported using an alcohol screening questionnaire in their practice increased significantly with the adequacy of their training, as did the proportion who said they were very prepared to assess alcohol use with their patients (Table 4Go). There was no statistically significant variation in the proportion of respondents who said they provide advice and education regarding prenatal alcohol use to all their patients by various levels of reported adequacy of their medical school training about alcohol use (Table 4Go). Similarly, perceived needs for improving alcohol use assessment in clinical practice did not vary significantly by the reported adequacy of their medical school training about alcohol use, except for the need for alcohol use training and consultation on alcohol use assessment (Table 4Go). The percentage of obstetrician–gynecologists who said they needed alcohol use training and consultation to improve their clinical practices was inversely related to the reported adequacy of their medical school training about alcohol use.


View this table:
[in this window]
[in a new window]
  		Table 4. Selected Obstetrician–Gynecologists’ Practices, Attitudes, and Needs by Adequacy of Medical School Training on Alcohol Use During Pregnancy
 
Among the survey responses assessed for gender variation, few were statistically significant after we adjusted for age (Tables 5Go, 6Go). Male respondents were significantly less likely than female respondents to advise abstinence when their patients reported moderate alcohol use (Table 5Go) or to indicate that having referral sources for their patients would improve their alcohol use assessment and management practices (Table 6Go). Conversely, male respondents were more likely than female respondents to believe that pregnant woman should completely abstain from alcohol use (P = .039) (Table 6Go).


View this table:
[in this window]
[in a new window]
  		Table 5. Age and Gender-Adjusted Prevalence Ratios for Assessment and Management of Patients’ Alcohol Use During Pregnancy
 

View this table:
[in this window]
[in a new window]
  		Table 6. Age- and Gender-Adjusted Prevalence Ratios for Knowledge, Attitudes, and Beliefs of Obstetrician–Gynecologists About Alcohol Use During Pregnancy
 
However, the year of medical school graduation was significantly associated with respondents’ responses to questions concerning alcohol use, even after we adjusted for gender (Tables 5Go, 6Go). Respondents who graduated before 1990 were significantly less likely to use an alcohol screening questionnaire than respondents graduating after 1989 (Table 5Go). For women who reported moderate drinking, respondents who graduated before 1973 were significantly less likely than more recent graduates to discuss adverse effects, advise abstinence, or advise a reduction in consumption. For women who report heavy drinking, respondents who graduated before 1990 were significantly less likely than respondents who graduated after 1989 to advise a reduction in alcohol consumption; respondents who graduated between 1973 and 1989 were also less likely to discuss adverse effects than those who graduated after 1989.

Respondents who graduated from medical school before 1973 were significantly more likely than those graduating after 1989 to be unsure of risk drinking levels per week or per occasion associated with one or more of the four adverse pregnancy outcomes cited (Table 6Go). Respondents graduating before 1990 were significantly more likely than those graduating after 1989 to report inadequate medical school training regarding prenatal alcohol use, to report a need for training in alcohol assessment and counseling, and to report a need for reimbursement for screening and assessment. However, respondents graduating before 1990 were significantly less likely than those graduating after 1989 to indicate that they felt very prepared to assess alcohol use in their patients.


   Discussion
Top
Abstract
 Materials and Methods
 Results
 Discussion
References
 
We found that almost all obstetrician–gynecologists query their patients about substance use at least once during their pregnancy, usually at the initial visit. These findings confirm those of other studies17,18 and are encouraging in light of the most recent recommendations from ACOG that advise clinicians to question pregnant women at their first prenatal visit about past and present alcohol, nicotine, and other drug use.8 In addition to asking their patients about alcohol use, 90% of respondents in this survey indicated that when prenatal drinking was reported, they asked further questions to determine the extent of the drinking, which has not always been reported in other studies. Brief and effective prenatal screening questionnaires have been developed in recent years and are recommended for use by ACOG.10 Only one in ten respondents in this survey reported using a screening questionnaire, with the most popular being the CAGE.16 This finding suggests the need to raise awareness among practicing obstetrician–gynecologists of the availability of alcohol screening questionnaires developed specifically for use among pregnant women.19,20 The T-ACE is a mnemonic for a four-item alcohol screening questionnaire that measures tolerance (T) to specific number of drinks; degree to which others are annoyed (A) by the respondent’s drinking; degree to which the respondent is considering cutting (C) down on drinking; and if the respondent ever (E) needed a drink first thing in the morning. The TWEAK is a mnemonic for a five-item questionnaire that measures tolerance (T); if close friends and families have worried about the respondent’s drinking in the past year (W); the eye-opener variable (E); if the respondent has been told they said and did things they don’t remember while drinking—amnesia (A); and the cut-down [K] variable. The Michigan Alcoholism Screening Test (MAST)21 also has been shown to be effective in detecting alcohol use among pregnant women.

Most respondents reported they discussed the adverse effects of alcohol use with pregnant women and advised abstinence, although they were more likely to do so among those who reported heavy drinking than those who reported moderate drinking. Opinions of drinking thresholds associated with selected adverse outcomes varied among survey respondents. One might argue that the effects of varying thresholds of prenatal use have not been defined sufficiently in the scientific literature with respect to maternal, fetal, and child health consequences. Although findings regarding the effects of moderate alcohol use on infant birth weight have been mixed, the potential for other adverse effects from moderate alcohol use, including spontaneous abortions, neurodevelopmental deficits, and birth defects, have been gaining increased attention.22–26 These reports imply the need to caution moderate drinkers regarding the potential adverse consequences of prenatal alcohol use.

Consistent with other reports,19,27 we found that obstetrician–gynecologists who graduated from medical school before 1989 were more likely to report uncertainty regarding alcohol thresholds associated with selected adverse pregnancy effects or to regard higher consumption levels to be without risk of these outcomes. Our findings of the most common barriers to alcohol assessment and counseling in clinical practice settings were similar to those previously reported,19,20,27 and included time limitations, patient sensitivity, a need for information and additional training to enhance ascertainment skills, and lack of referral resources. Four of ten respondents listed the need for more training in assessment and counseling of pregnant women who consume alcohol. Information on the levels at which alcohol causes adverse pregnancy outcomes (cited by 83% of respondents) was the most frequently mentioned need for improving assessments of alcohol use among pregnant women.

This study has some limitations. Respondents may have provided socially desirable answers to some questions, particularly in response to sensitive questions such as assessment and management. We attempted to limit self-report bias by asking several questions concerning opinions and viewpoints and assuring respondents of their anonymity in participating in the survey. Because the study group selection strategy included all Collaborative Ambulatory Research Network members and only a sample of other ACOG members, the analysis plan ideally should have used a weighting procedure to produce overall results that reflected the ratio of Collaborative Ambulatory Research Network members to all other ACOG members. However, the returned questionnaires did not have the information required to distinguish a Collaborative Ambulatory Research Network member from another ACOG member. Therefore, our results may be weighted more toward the responses of Collaborative Ambulatory Research Network members than toward the responses of the general ACOG membership. Further, it is impossible to know whether the overall 60% response rate applied uniformly to the 200 Collaborative Ambulatory Research Network and to the 800 other ACOG members in the study group. Because of these circumstances and the relatively low response rate, our results should be tempered with caution.

Though federal advisories in effect since 1981 call for pregnant women or women considering pregnancies to abstain from alcohol use,12–15 results of this survey indicate that many clinicians are not convinced that total abstinence from alcohol use is necessary for a pregnant woman. This disparity in viewpoints should be given attention by encouraging meaningful dialogue between professional organizations and public health agencies on this issue. Survey results also call for the renewed and combined efforts of federal, professional, and nonprofit agencies and organizations in raising public awareness of the potential risks of moderate and heavy alcohol use during pregnancy (including binge drinking), and to respond to barriers identified by clinicians as impediments to providing better assessment and counseling to pregnant women who consume alcohol. The study results also suggest the need to provide clinicians with updated information regarding the potential effects of moderate and heavy prenatal alcohol consumption and adverse pregnancy, infant, and child health outcomes; effective methods for screening for prenatal alcohol use; and brief intervention counseling techniques that can be used in primary health care settings28 for patients who screen positive. According to our findings, clinicians who graduated from medical school before 1989, and particularly those who graduated before 1973, are important target groups.


   Footnotes
 
PII S0029-7844(99)00616-X

Received June 21, 1999. Received in revised form October 13, 1999. Accepted October 22, 1999.


   References
Top
Abstract
 Materials and Methods
 Results
 Discussion
 References
 
1. Ebrahim SH, Luman ET, Floyd RL, Murphy CC, Bennett EM, Boyle CA. Alcohol consumption by pregnant women in the United States during 1988–1995. Obstet Gynecol 1998;92:187–92.[Abstract]

2. Ebrahim SH, Diekman ST, Floyd RL, Decoufle P. Comparison of binge drinking among pregnant and nonpregnant women, United States, 1991–1995. Am J Obstet Gynecol 1999;180:1–7.[Medline]

3. Lussky RC. Alcohol use during pregnancy: How health care providers can make a difference. Minn Med 1996;79:49–51.

4. Horton JA, Cruess DF, Pearse WH. Primary and preventive care services provided by obstetrician-gynecologists. Obstet Gynecol 1993;82:723–6.[Abstract/Free Full Text]

5. Nelson C, Woodwell D. National Ambulatory Medical Care Survey: 1993 Summary. Series 13: No. 136, DHHS Pub. No. (PHS 98-1797). Vital Health Stat 1998;13:136.

6. Substance abuse and the American woman. New York: National Center on Addiction and Substance Abuse, 1996.

7. Green LW, Eriksen MP, Schor EL. Preventive practices by physicians: Behavioral determinants and potential interventions. Am J Prev Med 1988;4:101–7.[Medline]

8. Guidelines for Perinatal Care. 4th ed. Elk Grove Village (IL): American Academy of Pediatrics; Washington (DC): American College of Obstetricians and Gynecologists, 1997:65–73.

9. Sokol RJ, Martier SS, Ager JW. The T-ACE questions: Practical prenatal detection of risk drinking. Am J Obstet Gynecol 1989;160: 863–70.[Medline]

10. American College of Obstetricians and Gynecologists. Substance abuse in pregnancy. ACOG technical bulletin no. 195. Washington (DC): American College of Obstetricians and Gynecologists, 1994.

11. Jones KL, Smith DW. Recognition of the fetal alcohol syndrome in early infancy. Lancet 1973;2:999–1001.[Medline]

12. Anonymous. Surgeon General’s advisory on alcohol and pregnancy. FDA Drug Bull 1981;11:9–10.[Medline]

13. Hankin JR, Sloan JJ, Firestone IJ, Ager JW, Sokol RJ, Martier SS, et al. The alcohol beverage warning label: When did knowledge increase? Alcohol Clin Exp Res 1993;17:428–30.[Medline]

14. Nutrition and your health: Dietary guidelines for Americans. 3rd ed. Washington (DC): US Department of Agriculture/US Department of Health and Human Services, 1990:25–6.

15. Nutrition and your health: Dietary guidelines for Americans. 4th ed. Washington (DC): US Department of Agriculture/US Department of Health and Human Services, 1995:40–1.

16. Mayfield D, McLeod G, Hall P. The CAGE questionnaire: Validation of a new alcoholism instrument. Am J Psychiatry 1974;131: 1121–3.[Abstract/Free Full Text]

17. Abel EK, Kruger M. What do physicians know and say about fetal alcohol syndrome: A survey of obstetricians, pediatricians, and family medicine physicians. Alcohol Clin Exp Res 1998;22:1951–4.[Medline]

18. The Alaska Fetal Alcohol Syndrome Prevention Steering Committee. Alcohol-related knowledge, attitude, belief and behavior surveys of Alaskan health professionals. Alaska Med 1995;37:5–10.[Medline]

19. Miner KJ, Holtan N, Braddock M, Cooper H, Kloehn D. Barriers to screening and counseling pregnant women for alcohol use. Minn Med 1996;79:43–7.

20. Russel M, Martier SS, Sokol RJ, Mudar P, Bottoms S, Jacobson S, et al. Screening for pregnancy risk-drinking. Alcohol Clin Exp Res 1994;18:1156–61.[Medline]

21. Selzer ML. The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. Am J Psychiatry 1971;127:1653–8.[Abstract/Free Full Text]

22. Lundsberg LS, Bracken MB, Saftlas AF. Low-to-moderate gestational alcohol use and intrauterine growth retardation, low birth-weight, and preterm delivery. Ann Epidemiol 1997;7:498–508.[Medline]

23. Windham GC, Von Behren J, Fenser L, Schaefer C, Swan SH. Moderate maternal alcohol consumption and risk of spontaneous abortion. Epidemiology 1997;8:509–14.[Medline]

24. Jacobson JL, Jacobson SW. Prenatal alcohol exposure and neurobehavioral development: Where is the threshold? Alcohol Clin Exp Res 1994;18:30–6.

25. Moore CA, Khoury MJ, Liu Y. Does light-to-moderate alcohol consumption during pregnancy increase the risk for renal abnormalities among offspring? Pediatrics 1997;99:E11 (http://www.pediatrics.org/cgi/content/full/99/4/e11).

26. Shaw GM, Lammer EJ. Maternal periconceptional alcohol consumption and risk for orofacial clefts. J Pediatr 1999;134:298–303.[Medline]

27. Nanson JL, Bolaria R, Snyder RE, Morse BA, Weiner L. Physician awareness of fetal alcohol syndrome: A survey of pediatricians and general practitioners. Can Med Assoc J 1995;152:1071–6.[Abstract]

28. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem drinkers: A randomized controlled trial in community-based primary care practices. JAMA 1997;277: 1039–45.[Abstract]




This article has been cited by other articles:


Home page
 Obstet GynecolHome page
K. Keeton, D. E. Fenner, T. R. B. Johnson, and R. A. Hayward
Predictors of Physician Career Satisfaction, Work-Life Balance, and Burnout
Obstet. Gynecol., April 1, 2007; 109(4): 949 - 955.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
S. Gahagan, T. T. Sharpe, M. Brimacombe, Y. Fry-Johnson, R. Levine, M. Mengel, M. O'Connor, B. Paley, S. Adubato, and G. Brenneman
Pediatricians' Knowledge, Training, and Experience in the Care of Children With Fetal Alcohol Syndrome
Pediatrics, September 1, 2006; 118(3): e657 - e668.
[Abstract] [Full Text] [PDF]

Home page
 J Am Board Fam MedHome page
V. L. Kvigne, G. R. Leonardson, J. Borzelleca, E. Brock, M. Neff-Smith, and T. K. Welty
Characteristics of Mothers Who Have Children with Fetal Alcohol Syndrome or Some Characteristics of Fetal Alcohol Syndrome
J Am Board Fam Med, July 1, 2003; 16(4): 296 - 303.
[Abstract] [Full Text] [PDF]

Home page
 Obstet GynecolHome page
N. L. Stanwood, J. M. Garrett, and T. R. Konrad
Obstetrician-Gynecologists and the Intrauterine Device: A Survey of Attitudes and Practice
Obstet. Gynecol., February 1, 2002; 99(2): 275 - 280.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by DIEKMAN, S. T.
Right arrow Articles by SOKOL, R. J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by DIEKMAN, S. T.
Right arrow Articles by SOKOL, R. J.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS