Alcohol Use and Binge Drinking Among Women of Childbearing Age — United States, 2011–2013

Cheryl H. Tan, MPH1; Clark H. Denny, PhD1; Nancy E. Cheal, PhD1; Joseph E. Sniezek, MD1; Dafna Kanny, PhD2

Excessive alcohol use* is risk factor for a wide range of health and social problems including liver cirrhosis, certain cancers, depression, motor vehicle crashes, and violence (1). Alcohol use during pregnancy can lead to fetal alcohol spectrum disorders (FASDs) and other adverse birth outcomes (1). Community studies estimate that as many as 2% to 5% of first grade students in the United States might have an FASD, which include physical, behavioral, or learning impairments (2). In 2005, the Surgeon General reissued an advisory† urging women who are or might be pregnant§ to abstain from alcohol consumption to eliminate the risk for FASDs or other negative birth outcomes. To estimate current prevalences of any alcohol use and binge drinking (consuming four or more drinks on an occasion) among pregnant and nonpregnant women aged 18–44 years in the United States, CDC analyzed 2011–2013 Behavioral Risk Factor Surveillance System (BRFSS) data. Among pregnant women, the prevalences of any alcohol use and binge drinking in the past 30 days were 10.2% and 3.1%, respectively. Among nonpregnant women, the prevalences of any alcohol use and binge drinking in the past 30 days were 53.6% and 18.2%, respectively. Among binge drinkers, pregnant women reported a significantly higher frequency of binge drinking than nonpregnant women (4.6 and 3.1 episodes, respectively); the largest amount consumed during binge drinking was also higher among pregnant women than nonpregnant women (7.5 versus 6.0 drinks), although this difference was not statistically significant. Implementation of evidence-based clinical and community-level strategies would be expected to reduce binge drinking among pregnant women and women of childbearing age, and any alcohol consumption among women who are or might be pregnant. Healthcare professionals can support these efforts by implementing alcohol screening and brief interventions in their primary care practices, and informing women that there is no known safe level of alcohol consumption when they are pregnant or might be pregnant (3).

BRFSS is a state-based, random-digit–dialed telephone survey¶ of the noninstitutionalized U.S. population aged ≥18 years that collects information on health conditions and risk behaviors, including alcohol use. CDC aggregated and analyzed BRFSS data from 2011–2013 from all 50 states and the District of Columbia for 206,481 women aged 18–44 years, 8,383 (4.0%) of whom were pregnant at the time of interview. The median response rate** among states ranged from 45.2% to 49.7% for 2011–2013. The prevalence of any alcohol use (any alcohol consumption in the past 30 days) and the prevalence of binge drinking (four drinks or more on at least one occasion in the past 30 days) were estimated for both pregnant and nonpregnant women. The prevalences and 95% confidence intervals (CIs) of these drinking patterns also were examined across different sociodemographic characteristics (age, race/ethnicity, education, employment status, and marital status). Adjusted prevalence ratios (aPRs) and CIs were calculated using logistic regression analysis to examine the association between the prevalences of the two drinking patterns and each sociodemographic characteristic, while controlling for the other sociodemographic characteristics. Finally, among women who reported binge drinking, frequency (the number of binge drinking episodes in the past 30 days) and intensity (the largest number of drinks consumed during any episode in the past 30 days) were estimated. Frequency and intensity across sociodemographic characteristics could only be estimated for nonpregnant women who reported binge drinking, because of the small sample size among pregnant women. Data were weighted to represent state-level population estimates and aggregated to represent a nationwide estimate. Analyses using SUDAAN 11.0 accounted for the complex sampling design.

Among nonpregnant women, the prevalence of any alcohol use was 53.6% and the prevalence of binge drinking was 18.2% (Table 1). Among pregnant women, the prevalence of any alcohol use was 10.2% and the prevalence of binge drinking was 3.1% (Table 2); within this group, women aged 35–44 years reported a significantly higher prevalence of any alcohol use (18.6%) than all other age groups. Among pregnant women, the prevalence of any alcohol use was twice as high among those with a college degree than among those with a high school diploma or less (aPR = 2.1), and was 2.4 times higher among nonmarried women than among married women. The prevalence of binge drinking among nonmarried pregnant women was 4.6 times the prevalence among married pregnant women.

Although the overall prevalence of binge drinking was higher among nonpregnant women, among all women who reported binge drinking in the past 30 days, pregnant women reported an average of 4.6 binge drinking episodes, which was significantly higher than the average of 3.1 such episodes reported by nonpregnant women (p = 0.044); the intensity of binge drinking was not significantly higher among pregnant women (7.5 drinks) than among nonpregnant women (6.0 drinks). Among nonpregnant women who reported binge drinking, those aged 18–20 years reported the highest frequency (3.9 episodes) and intensity (7.1 drinks) (Table 3).

Discussion

During 2011–2013, one in 10 pregnant women reported consuming alcohol in the past 30 days and one in 33 reported binge drinking; similar to nonpregnant women, about one third of pregnant women who consume alcohol engage in binge drinking. Among all women who reported binge drinking, pregnant women reported a higher frequency of binge drinking than nonpregnant women. One possible explanation for this might be that women who binge drink during pregnancy are more likely to be alcohol-dependent than the average female binge drinker, and therefore binge drink more frequently. A recent U.S. study found that among adult binge drinkers, the prevalence of alcohol dependence increased significantly with the frequency of binge drinking (4). Women who binge drink during pregnancy and are not alcohol-dependent would benefit from alcohol screening and brief intervention, which involves screening patients using validated questions, followed by a brief counselling intervention to advise patients who screen positive to set goals and take steps toward reducing their alcohol consumption (3,5). Patients with more severe alcohol problems should be referred for specialized care (3). Since previous research found no significant difference in binge drinking frequency between pregnant and nonpregnant binge drinkers, future surveillance should monitor the frequency of binge drinking to see if this pattern persists (6). Consistent with previous reports, the prevalence of alcohol consumption among pregnant women was higher among those with a college degree than among those with less education (6). This might be related to higher discretionary income among women with college degrees, or social acceptability of alcohol consumption and binge drinking established during college years, or a combination of these or other determinants.

The prevalence of any alcohol use and binge drinking among pregnant and nonpregnant women in this study is slightly higher than estimates reported for 2006–2010 (6). The differences in estimates between the two periods are likely related to methodological changes in the BRFSS in 2011, rather than actual shifts in the prevalence of alcohol use (7). Specifically, the BRFSS began sampling respondents using cellular phones in addition to landline phones, and changed the weighting method from poststratification to "raking" (iterative proportional fitting) (7). These changes have been associated with a higher estimated prevalence of excessive alcohol use among U.S. adults (7).

The findings in this study are subject to at least five limitations. First, self-reported alcohol use is generally underreported (8). Second, pregnancy status might also have been underreported because a majority of women do not recognize they are pregnant until at least 4 weeks gestation (9). Third, some prevalence estimates and ratios of binge drinking among pregnant women had to be suppressed because of unreliable estimates (relative standard errors >0.3). Fourth, the results could be subject to selection bias since the median response rate was <50% for all 3 years. Finally, changes in BRFSS methodology in 2011 did not allow estimates from 2011–2013 to be compared with estimates from earlier years.

There is a need for a comprehensive approach to reduce alcohol use and binge drinking among pregnant women, and binge drinking among women of childbearing age. Healthy People 2020 established objectives†† to increase the percentage of pregnant women reporting abstinence from any alcohol use to 98% (MCH 11.1), and to increase the percentage reporting abstinence from binge drinking to 100% (MCH 11.2). The Community Preventive Services Task Force recommends several population-level strategies for reducing excessive alcohol consumption and related harms. These include limiting alcohol outlet density (the number of places in a given area where alcohol may be legally sold for onsite consumption), holding alcohol retailers liable for harms related to the sale of alcohol to minors and intoxicated patrons (dram shop liability), and increasing alcohol taxes (10). The U.S. Preventive Services Task Force also recommends alcohol screening and brief intervention in primary care settings for persons aged ≥18 years, including pregnant women (5). Under the Affordable Care Act, many health insurance plans cover alcohol screening and brief intervention at no cost to the insured.§§ In addition, CDC funded and is working with Fetal Alcohol Spectrum Disorders Practice and Implementation Centers and National Partners¶¶ to promote systems level practice changes among providers, through training and implementation of evidence-based FASD prevention approaches. Adopting this comprehensive approach to reduce excessive alcohol use among pregnant women and women of childbearing age is an important step toward achieving the Healthy People 2020 objectives of reducing alcohol use among pregnant women, and ultimately reducing FASDs and other alcohol-related adverse birth outcomes.

Acknowledgments

Behavioral Risk Factor Surveillance System state coordinators. Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee.

1Div of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities; 2Div of Population Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Corresponding author: Cheryl H. Tan, ctan1@cdc.gov, 404-498-6720.

References

Summary What is already known on this topic? Excessive alcohol use is a risk factor for a wide range of health and social problems including liver cirrhosis, certain cancers, depression, motor vehicle crashes, and violence. Alcohol consumption during pregnancy is also a risk factor for fetal alcohol spectrum disorders (FASDs) and other adverse birth outcomes, making alcohol use during pregnancy a leading preventable cause of birth defects and developmental disabilities. There is no known safe amount of alcohol consumption during pregnancy. What is added by this report? Based on 2011–2013 Behavioral Risk Factor Surveillance System data, one in 10 (10.2%) pregnant women aged 18–44 years reported consuming alcohol in the past 30 days, and 3.1% reported binge drinking in the past 30 days. Similar to nonpregnant women, about one third of pregnant women who consume alcohol engage in binge drinking. Among binge drinkers, pregnant women reported a statistically significant higher frequency of binge drinking than nonpregnant women. What are the implications for public health practice? Implementation of evidence-based strategies would be expected to reduce binge drinking among pregnant women and women of childbearing age, and any alcohol consumption among women who are or might be pregnant. These strategies include alcohol screening and brief intervention as recommended by the U.S. Preventive Services Task Force, and community-level strategies as recommended by the Community Preventive Services Task Force.

TABLE 1. Estimated percentages* and adjusted prevalence ratios of nonpregnant women aged 18–44 years (N = 198,098) who reported any alcohol use or binge drinking,† by selected characteristics — Behavioral Risk Factor Surveillance System, United States, 2011–2013 Characteristic Any use Binge drinking % (95% CI) aPR§ (95% CI) % (95% CI) aPR§ (95% CI) Overall 53.6 (53.2–54.0) — — 18.2 (17.9–18.5) — — Age group (yrs)¶ 18–20 32.5 (31.0–33.9) 0.6 (0.6–0.6) 15.0 (14.0–16.1) 0.5 (0.5–0.6) 21–24 66.1 (64.9–67.2) Referent 29.2 (28.2–30.3) Referent 25–29 60.1 (59.1–61.1) 0.9 (0.9–0.9) 23.6 (22.8–24.5) 0.9 (0.8–0.9) 30–34 53.6 (52.7–54.5) 0.8 (0.8–0.8) 16.5 (15.9–17.2) 0.7 (0.6–0.7) 35–44 52.7 (52.1–53.3) 0.8 (0.8–0.8) 13.4 (13.0–13.8) 0.5 (0.5–0.6) Race/Ethnicity White, non-Hispanic 59.7 (59.2–60.1) 1.3 (1.2–1.3) 21.4 (21.0–21.8) 1.5 (1.4–1.6) Black, non-Hispanic 49.6 (48.4–50.7) 1.1 (1.0–1.1) 13.6 (12.8–14.4) 0.9 (0.8–1.0) Hispanic 40.9 (39.8–42.0) Referent 13.2 (12.4–14.0) Referent Other, non-Hispanic 47.6 (45.9–49.3) 1.0 (0.9–1.0) 14.9 (13.7–16.1) 1.0 (0.9–1.1) Education High school diploma or less 39.4 (38.6–40.1) Referent 14.6 (14.1–15.2) Referent Some college 56.3 (55.6–57.0) 1.3 (1.3–1.3) 19.8 (19.2–20.4) 1.2 (1.2–1.3) College degree 69.6 (69.0–70.1) 1.6 (1.5–1.6) 21.0 (20.5–21.5) 1.3 (1.3–1.4) Employment status Employed 60.8 (60.3–61.3) 1.2 (1.2–1.2) 20.3 (19.9–20.7) 1.3 (1.2–1.3) Not employed 43.6 (42.9–44.3) Referent 15.2 (14.7–15.7) Referent Marital status Married 54.0 (53.4–54.5) Referent 13.4 (13.1–13.8) Referent Not married 53.3 (52.7–53.9) 1.1 (1.1–1.1) 21.7 (21.2–22.2) 1.6 (1.5–1.7)

TABLE 2. Estimated percentages* and adjusted prevalence ratios of pregnant women aged 18–44 years (n = 8,383) who reported any alcohol use or binge drinking,† by selected characteristics — Behavioral Risk Factor Surveillance System, United States, 2011–2013 Characteristic Any use Binge drinking % (95% CI) aPR§ (95% CI) % (95% CI) aPR§ (95% CI) Overall 10.2 (9.1–11.4) — — 3.1 (2.6–3.8) — — Age group (yrs)¶ 18–20 8.0 (5.6–11.2) 0.8 (0.5–1.3) 4.3** (2.7–6.7)** 1.0** (0.6–1.8)** 21–24 10.0 (7.7–12.8) Referent 4.2 (2.9–5.9) Referent 25–29 8.0 (6.4–10.1) 0.9 (0.6–1.3) 2.2** (1.4–3.4)** 0.7** (0.4–1.2)** 30–34 8.7 (6.9–11.0) 1.0 (0.7–1.5) 2.7** (1.6–4.4)** 1.0** (0.5–1.9)** 35–44 18.6 (14.8–23.2) 2.1 (1.5–2.9) 3.6** (2.3–5.5)** 2.1** (1.5–2.9)** Race/Ethnicity White, non-Hispanic 9.6 (8.5–10.9) 1.0 (0.7–1.3) 3.5 (2.8–4.4) NA†† NA†† Black, non-Hispanic 13.9 (10.0–19.0) 1.2 (0.8–1.9) NA†† NA†† NA†† NA†† Hispanic 9.1 (6.9–12.0) Referent 2.9 (1.7–4.9) NA†† NA†† Other, non-Hispanic 11.0** (7.2–16.3)** 0.9** (0.6–1.5)** NA†† NA†† NA†† NA†† Education High school diploma or less 7.7 (6.2–9.6) Referent 2.9 (2.0–4.1) Referent Some college 10.9 (8.9–13.3) 1.6 (1.2–2.1) 3.8 (2.7–5.2) 1.6 (1.0–2.5) College degree 13.0 (11.0–15.4) 2.1 (1.5–2.9) 2.9 (2.1–3.9) 1.6 (0.9–2.8) Employment status Employed 12.0 (10.4–13.9) 1.3 (1.0–1.6) 3.6 (2.8–4.5) 1.4 (0.9–2.0) Not employed 8.1 (6.8–9.8) Referent 2.7 (1.9–3.7) Referent Marital status Married 7.9 (6.7–9.3) Referent 1.6 (1.1–2.2) Referent Not married 12.9 (11.1–15.0) 2.4 (1.8–3.1) 5.0 (3.9–6.3) 4.6 (2.8–7.5)