Fetal Alcohol Syndrome: Diagnosis, Epidemiology, Prevention, and Treatment (1996)

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6
Epidemiology of Women's Drinking

Publicity about FAS has undoubtedly increased concern about women's drinking and vice versa. However, these two major areas of research have remained relatively isolated from one another. Studies of FAS have primarily addressed biomedical and clinical concerns: offspring characteristics and diagnosis, mechanisms of alcohol effects, dose-response relationships, and effects of prevention efforts in clinical and community settings. FAS-oriented research on pregnant women who drink has focused primarily on measuring alcohol consumption and on identifying women at risk for giving birth to children with FAS, ARBD, or ARND because of their alcohol abuse. Much of this research, however, has paid relatively little attention to psychological and social determinants of maternal drinking behavior. Although surveillance studies have monitored trends in alcohol consumption among women of childbearing age (e.g., the Behavioral Risk Factors Surveys of the Centers for Disease Control and Prevention [CDC]), such surveys are restricted for the most part to assessing a few demographic characteristics, and most have serious limitations in their measurement of alcohol use, reproductive history, and potential predictors of drinking patterns. Studies of pregnant women have rarely attempted to apply findings from recent research on drinking among women in general to better understand influences on pregnant women's drinking behavior.

Although researchers have seen changes in drinking patterns during pregnancy over the years, there is no substantive evidence of any change in drinking behavior among women who drink more heavily or abuse alcohol, either in terms of proportions of heavy drinkers at the time of conception or in terms of consumption levels during pregnancy (Hankin et al., 1993a,b). To learn why some

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pregnant women continue to drink at hazardous levels despite factual knowledge about fetal risks, it is vital to understand the personal and social-environmental risk factors that support maternal drinking (May, in press; Waterson and Murray-Lyon, 1990; Weiner et al., 1989). Related research on women's drinking more generally may provide some answers for understanding the determinants of pregnant women's drinking behavior.

The following sections discuss (1) methodological considerations, (2) definitions and patterns of drinking among women, and (3) needed research on pregnant women's drinking.

METHODOLOGIC CONSIDERATIONS

Conceptualizing and measuring factors that increase the likelihood of drinking among pregnant women represent a complex task. These factors are likely to differ (1) for drinking in early pregnancy versus continued drinking throughout pregnancy; (2) for any alcohol use during pregnancy versus heavier consumption during pregnancy; and (3) for alcohol use during pregnancy versus alcohol abuse or dependence. In addition, learning more about factors that influence women of childbearing age to drink and to abuse alcohol could tell us which women are most likely to be drinking at high-risk levels before pregnancy is recognized.

In addition to personal and environmental risk factors that affect maternal drinking behavior, other factors may combine with alcohol either to reduce or to exacerbate fetal risks. For example, the incidence of FAS among "heavy" drinkers, variously defined (see discussion below), ranges widely but has never been found to be more than 40 percent in any study (Abel, in press). FAS is not unlike other teratogens in this regard. Very few, if any, teratogens have "attack rates" of 100%. A better understanding of biological and life-style characteristics associated with variations in fetal risk at comparable levels of maternal alcohol consumption is needed to understand the diversity in fetal outcome and might suggest prevention strategies that could strengthen naturally occurring protection against adverse fetal effects (Faden and Hanna, 1994).

During the past two decades, research on alcohol use in pregnancy has become increasingly international, including studies from the United Kingdom, France, Norway, Sweden, New Zealand, a multinational European collaborative project, and others (e.g., Plant et al., 1993; Tolo and Little, in press; Waterson and Murray-Lyon, 1989, 1990). However, studies abroad have uncertain utility for detecting social influences on drinking during pregnancy in the United States. For example, frequent alcohol consumption during pregnancy was not related to smoking behavior in a recent national study of women in New Zealand (Counsell et al., 1994). This finding diverges from those in most U.S. studies, which usually find drinking in pregnancy to be associated with smoking (Serdula et al., 1991). Because of the questionable relevance of some international data to social

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risk factors in this country, the present discussion emphasizes studies conducted in the United States.

Studies of Pregnant Women in Clinical Settings

Most of what is known about correlates of drinking during pregnancy come from studies of pregnant women in hospitals and prenatal clinics. Findings from these clinic-based studies have several methodological limitations. Many of these studies have been conducted in settings that serve special or high-risk populations (e.g., inner-city hospitals serving predominantly lower-socioeconomic status [SES] patients). The socioeconomic background, ethnic composition, and locations of these clinical samples may limit the degree to which their findings can be generalized.

An additional shortcoming of current clinic-based studies is that most include relatively small numbers of women who are heavier drinkers, alcohol abusers, or alcohol dependent. Most women drinkers stop or drastically reduce their drinking when pregnant (Serdula et al., 1991). In the University of Pittsburgh's Maternal Health Practices and Child Development (MHPCD) Project, for example, only 4.6 percent of women reported drinking an average of one drink per day by the end of the third trimester of pregnancy, compared with 44 percent reporting one or more drinks per day before pregnancy (Day et al., 1993). While this striking reduction in alcohol consumption during pregnancy may reduce fetal risk, the small numbers of heavier drinkers in most clinic-based studies, and the limited variation in drinking levels among pregnant women who do drink, reduce the statistical ''power" to detect predictors of maternal drinking behavior.

A final limitation of many clinic-based studies is that most have measured only a few demographic characteristics as predictors of maternal drinking and its effects. Few studies of drinking during pregnancy assess personality or social-environmental variables associated with drinking. Factors such as depression, low self-esteem, family history of alcoholism, partner drinking, sexual dysfunction, and sexual abuse or other violent victimization have related to drinking in studies of women in general (e.g., Miller et al., 1993; Wilsnack, in press, a,b) and may be predictive of drinking behavior for pregnant women as well. Also largely unexplored are the dietary behaviors that may affect biological susceptibilities to alcohol's effects (e.g., intake of antioxidants) (Abel and Hannigan, in press). Learning more about such personal, social, and biological risk factors for drinking in pregnancy might permit prevention efforts to be targeted more effectively to specific maternal risk drinkers.

Studies of Pregnant Women in the General Population

One way to overcome the limitations of smaller and less representative clinical samples is to survey large representative samples of pregnant women in the

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general population. Because only a small percentage of women are pregnant at any point, only general population surveys with very large samples will allow reliable analysis of drinking correlates among women pregnant at the time of the survey. Some very large national data sets are available that include information on women's drinking behavior, drinking-related problems, and a variety of other health behaviors (see NIAAA, 1994). Unfortunately, many of the largest national alcohol and health surveys (some with samples of more than 40,000 respondents) have not included questions about respondents' pregnancy status. Some examples of large national data sets that do include information about pregnancy status are described in Box 6-1.

Other Issues

Large general population samples of pregnant women will not solve all the problems of measuring alcohol use during pregnancy. Underreporting of alcohol consumption appears to vary by stage of pregnancy (e.g., Day et al., 1993) and may be substantial: recent drug studies suggest that substance use reported in pregnancy may need an upward correction by a factor of three or more (Dicker and Leighton, 1994). It should be borne in mind that reasons for underreporting of illegal substance use may be different from reasons for underreporting alcohol use, and the correction factors may be different. Underreporting obviously complicates the task of estimating dose-response relationships. Valid, sensitive, and specific measures of alcohol exposure in women and in pregnant women, when available, could be very useful. See Chapter 7 for more discussion of potential markers. In addition, it is uncertain whether underreporting may vary systematically (e.g., with drinking levels, education and SES, prenatal care, and other health and life-style variables) in ways that may bias observed relationships between alcohol use during pregnancy and possible risk or protective factors.

Efforts to identify high-risk demographic categories for drinking during pregnancy may overlook heterogeneity within such categories. Thus, in the United States, both clinic-based studies (Day et al., 1993) and population-based surveys (Faden et al., 1994) find bimodal distributions of drinking within several ethnic minority groups. For example, both abstention rates and rates of heavier drinking tend to be higher among pregnant African Americans, Native Americans, and Native Canadians. Heterogeneity is also characteristic of incidence rates for FAS in different communities, with FAS occurring more often in areas characterized by poverty compared with more affluent settings or in areas with cultural lifestyles that include heavy drinking compared to the general population (Abel, in press).

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DEFINITIONS AND PATTERNS OF DRINKING
AMONG U.S. WOMEN

Women in the General Population

Alcohol consumption patterns among women in the general U.S. population provide a context for discussing drinking behavior of pregnant women. Approximately 60 percent of adult women in the United States drink alcohol at least occasionally. Of these, the large majority consume small to moderate amounts of alcohol without adverse social, behavioral, or health consequences. In a 1991 U.S. national survey of 1099 women age 21 and older, 58 percent had consumed alcohol in the past 12 months: 44 percent of the sample were classified as light drinkers (women who reported consuming an average of 0-3 standard drinks per week); 12 percent were classified as moderate drinkers (4-13 drinks per week); and 3 percent were classified as heavy drinkers (14 or more drinks per week) (Wilsnack et al., 1994). Rates of drinking and heavy drinking tend to be highest among young women and to decline steadily with age. In the 1991 national survey, for example, 73 percent of women in their twenties and 69 percent of women in their thirties had consumed alcohol in the past 12 months; 4 percent of women in their twenties and thirties reported consuming at least 14 drinks per week. Despite concerns about an "epidemic" of alcohol problems in women in the 1970s and 1980s (e.g., Fillmore, 1984), rates of drinking and heavy drinking have been relatively stable among both women and men, with modest increases in the 1970s and modest declines since the early 1980s (Midanik and Clark, 1994; Williams and DeBakey, 1992; Wilsnack et al., 1994).

Pregnant Women

Available data indicate substantially lower rates of both drinking and heavier drinking among pregnant women, relative to nonpregnant women of childbearing age. For example, less than 25 percent of pregnant women reported any use of alcohol in the 1989 National Longitudinal Survey of Youth (20 percent); the 1988 National Maternal and Infant Health Survey (NMIHS; 21 percent); the 1991 CDC Behavioral Risk Factors Surveillance Survey (BRFSS; 14 percent); and the 1994 National Institute on Drug Abuse (NIDA) Pregnancy and Health Survey (19 percent). By comparison, the NIDA survey estimates that 20 percent of pregnant woman smoked, 5.5 percent used any illicit drugs, 0.9 percent used crack cocaine, and 10 percent used psychotherapeutics for medically-indicated conditions. Trend data suggest a significant decline in prenatal alcohol use during the past decade. For example, annual BRFSS surveys conducted in 21 states between 1985 and 1988 found that pregnant women's self-reports of any alcohol consumption in the past month declined from 32 percent to 20 percent over the study period (Serdula et al., 1991).

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The dramatic reduction in most women's alcohol consumption when they become pregnant affects how drinking levels are defined in studies of drinking and pregnancy. As just described, use of a standard general population definition of "heavy drinking" (e.g., the criterion of 14 or more drinks per week reached by 4 percent of women age 21-40 in the 1991 U.S. BRFSS survey) would identify fewer than 0.5 percent of pregnant women in most FAS-related studies. This downward shift in drinking distributions in pregnancy helps explain why alcohol and pregnancy research typically uses lower cutoffs for moderate and heavy drinking (e.g., one or more standard drinks per day to define heavy drinking) than do general population surveys (which in turn use lower cutoffs than many popular images of "heavy" drinking). Precise specification of consumption levels considered as "moderate" or "heavy" can aid both professionals and the general public in understanding the implications of scientific research on the fetal effects of maternal alcohol consumption.

Although definitions of heavy drinking vary across studies, rates tend to be very low regardless of the definition used. For example, data from the 1991 BRFSS survey shows that 2 percent of all women of child-bearing age but only 0.3 percent of pregnant women reported drinking 60 or more drinks during the preceding month and 21 percent of all women of child-bearing age but only 1.3 percent of pregnant women reported binge drinking (five or more drinks on at least one occasion) during the preceding month (Centers for Disease Control and Prevention, 1994). Although 45 percent of the respondents to the 1988 NMIHS survey reported drinking alcohol during the 3 months before they learned of their pregnancy, 21 percent drank after they learned of their pregnancy, 0.6 percent had six or more drinks per week during pregnancy, and 0.2 percent reported average consumption of two or more drinks per day (Centers for Disease Control and Prevention, 1995). In four states collaborating in a Pregnancy Risk Assessment Monitoring System (PRAMS) in 1988-1989, proportions of pregnant women reporting consumption of 14 or more drinks per week ranged from 0.03 percent to 0.13 percent (Bruce et al., 1993). Although these percentages are small in relative terms, the large absolute numbers of women who continue to engage in heavy and hazardous drinking throughout pregnancy make it imperative to understand the personal and social factors that make women more likely to continue drinking heavily during pregnancy.

Correlates of Drinking in Pregnancy

Correlates of drinking in early pregnancy are similar to those for women of childbearing age in general. This is because women often don't know they are pregnant until a month or two has passed. They therefore engage in their customary drinking habits early in pregnancy. The correlates include being Caucasian, older, and more educated (Streissguth et al., 1991). Although a number of studies compare correlates of drinking behavior in earlier versus later stages of pregnancy,

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little attention has been given to correlates of first-trimester drinking before and after pregnancy is confirmed: Do women who change their drinking patterns immediately upon learning of, or suspecting, pregnancy differ from women who change their drinking behavior more gradually?

Older pregnant women in some national samples were more likely than younger pregnant women to report drinking (Centers for Disease Control and Prevention, 1995; National Institute on Drug Abuse, 1994; Serdula et al., 1991), but the percentage of women over 25 years of age who drank during pregnancy has decreased between 1985 and 1988 to that of women 18 to 24 years of age. The NMIHS, a survey of women who gave birth in 1988, suggests that women who drink while pregnant are more likely to be white, more educated, of a higher income level, married, or smokers (Centers for Disease Control and Prevention, 1995). That same survey showed that heavy drinking while pregnant was more prevalent among women who were more than 35 years of age, non-white, and unmarried. Other factors associated with heavy drinking in these pregnant women were low annual household income and no prenatal care. Other studies tend to support that general profile of pregnant women who drink (Day et al., 1993; Waterson and Murray-Lyon, 1990). Correlates of continued drinking during pregnancy despite information on the risks and referral for intervention include onset of drinking behaviors at a young age, heavy drinking on the part of parents and siblings (especially female relatives), evidence of alcohol-related physical problems, and qualifying for a diagnosis of alcohol dependence (Smith et al., 1987).

The list of correlates of drinking during pregnancy is quite short when compared with the broader range of predictors that have been identified or suggested for drinking among women in general. These predictors include familial and genetic factors (e.g., maternal or paternal alcoholism); demographic and social role variables (e.g., lack of social roles, nontraditional employment, unemployment, cohabitation, divorce or separation); individual psychological factors (e.g., depression, anxiety, low self-esteem, eating disorders); relationship variables (e.g., partner's drinking, relationship conflict/violence, sexual dysfunction), physical and sexual victimization; and drinking contexts (including drinking behavior of coworkers and significant others) (see Galanter et al., in press; Gomberg and Nirenberg, 1993; Wilsnack, in press, a,b).

NEEDED RESEARCH ON PREGNANT WOMEN'S DRINKING

Increased Coordination of Research on FAS and Women's Drinking

Increased communication between FAS researchers and researchers studying women's drinking more generally might give FAS researchers a broader framework for detecting risk factors that affect drinking during pregnancy, which in turn might suggest new approaches to FAS prevention. For example, if depression

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or anxiety strongly predicted continued drinking in pregnancy, this might suggest evaluating psychotherapeutic interventions for these conditions. Associations between pregnant women's heavy drinking and their partners' heavy alcohol or drug use (Abel, 1983), or violent behavior by their partners, might suggest interpersonal and environmental approaches for reducing these women's alcohol use (Masis and May, 1991; Weiner et al., 1989).

Increased Secondary Analysis of National Health
and Alcohol Use Surveys

Several large national data sets that contain information on both alcohol use and reproductive history may be of value for examining correlates of drinking and heavy drinking among women of childbearing age, and correlates of drinking and heavy drinking among women pregnant at the time of the surveys. In addition to demographic characteristics, creative use of other information available in the data sets may allow the discovery of additional risk factors even without new data collection. Results of such secondary analyses could then be applied to the design of pregnancy-specific epidemiologic research. National surveys that lack adequate measures of either pregnancy status or alcohol use, however, cannot be employed for these purposes. Inclusion of standard questions about alcohol use and reproductive history in future large national health surveys, as appropriate, will pay high dividends in increased knowledge about drinking during pregnancy, its causes, and its effects. It could also be of benefit if national health surveys, as appropriate, included carefully selected variables (potential risk factors) that have shown strong and consistent relationships to women's drinking and drinking problems in other research.

Inclusion of Ethnic and Other Subgroup Populations in
Studies of Drinking in Pregnancy

The large differences in FAS prevalence rates across several racial and ethnic groups are discussed elsewhere in this chapter (see also Abel, in press). In addition to biological and environmental factors that may contribute to these differences in pregnancy outcomes, differences between and within ethnic groups affect pregnant women's drinking behavior in ways that are poorly understood. Culture shapes women's expectations and experiences of both pregnancy and alcohol use (Abel and Hannigan, in press; May et al., 1983). There is a particular need for research on ethnic differences in patterns of alcohol use or nonuse during pregnancy, and on ethnic similarities or differences in women's responses to education and prevention programs designed to reduce the risks of drinking in pregnancy.

Research discussed earlier suggests that a woman's age and socioeconomic status when she becomes pregnant may influence how she uses or abstains from

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alcohol (Abel and Hannigan, in press). Effective interventions to reduce risks of FAS may require an understanding of age- and status-specific risk factors (e.g., employment experiences) in addition to ethnic and cultural influences. Other potentially important subgroups include unmarried versus married mothers, and women living in heavier-drinking environments (e.g., with a partner who drinks heavily) versus lighter- or nondrinking environments.

Substance-Specific Versus Multiple-Substance Risk Factors

Although much of this discussion has focused on women's use of alcohol during pregnancy, many women who drink during pregnancy abuse other licit and illicit substances as well (Hingson et al., 1982; Serdula et al., 1991; Waterson and Murray-Lyon, 1989). Comparative data on women's use of various substances in combination with alcohol during pregnancy (e.g., Day et al., 1993) are scarce and should be obtained for larger and more representative samples. Studies designed to learn whether risk and protective factors are the same or different for different substances (e.g., alcohol, tobacco, marijuana), and for various specific combinations of substances, could have important implications for the development of single-substance versus multiple-substance approaches to education and prevention.

CONCLUSIONS AND RECOMMENDATIONS

The committee concludes that clinic-based studies of pregnant women have included only a limited range of biologic and psychosocial variables as possible risk factors for drinking in pregnancy. Furthermore, most large national health surveys contain inadequate data on women's drinking or pregnancy status. The lack of such data severely limits the ability to predict which women are most likely to engage in high-risk drinking during pregnancy or to give birth to a child with FAS, ARND, or ARBD. Therefore, the committee recommends special attention to the following research questions and issues:

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REFERENCES

Abel EL. Marihuana, Tobacco, Alcohol, and Reproduction. Boca Raton, FL: CRC Press, 1983.

Abel EL. An update on incidence of FAS: FAS is not an equal opportunity birth defect. Neurotoxicology and Teratology, in press.

Abel EL, Hannigan JH. Maternal risk factors in fetal alcohol syndrome: Provocative and permissive influences. Neurotoxicology and Teratology, in press.

Bruce FC, Adams MM, Shulman HB, Martin ML. Alcohol use before and during pregnancy. American Journal of Preventive Medicine 1993; 9:267-273.

Centers for Disease Control and Prevention. Frequent alcohol consumption among women of childbearing age—Behavioral risk factor surveillance system, 1991. Journal of the American Medical Association 1994; 271:1820-1821.

Centers for Disease Control and Prevention. Sociodemographic and behavioral characteristics associated with alcohol consumption during pregnancy—United States, 1988. Morbidity and Mortality Weekly Report 1995; 44:261-264.

Counsell AM, Smale PN, Geddis DC. Alcohol consumption by New Zealand women during pregnancy. New Zealand Medical Journal 1994; 107:278-281.

Day NL, Cottreau CM, Richardson GA. The epidemiology of alcohol, marijuana, and cocaine use among women of childbearing age and pregnant women. Clinical Obstetrics and Gynecology 1993; 36:232-245.

Dicker M, Leighton EA. Trends in the US prevalence of drug-using parturient women and drug-affected newborns, 1979 through 1990. American Journal of Public Health 1994; 84:1433-1438.

Faden VB, Graubard BI, Dufour M. Drinking by expectant mothers - What does it mean for their babies? Working paper, Division of Biometry and Epidemiology, National Institute on Alcohol Abuse and Alcoholism, 1994.

Faden VB, Hanna EZ. Alcohol and pregnancy—To drink or not to drink? Paper Presented at the Conference on Psychosocial and Behavioral Factors in Women's Health. American Psychological Association, Washington, DC, 1994.

Fillmore KM. "When angels fall": Women's drinking as cultural preoccupation and as reality. Alcohol problems in women: Antecedents, consequences, and intervention. S. C. Wilsnack and L. J. Beckman (eds.). New York: Guilford Press, 1984.

Galanter M, Begleiter N, Deitrich R, Gallant D, Goodwin D, Gottheil E et al. Recent Developments in Alcoholism. Volume 12: Alcoholism in Women. New York: Plenum, in press.

Gomberg ESL, Nirenberg RD. Women and Substance Abuse. Norwood, New Jersey: Ablex, 1993.

Hankin JR, Firestone IJ, Sloan JJ, Ager JW, Goodman AC, Sokol RJ et al. The impact of the alcohol warning label on drinking during pregnancy. Journal of Public Policy & Marketing 1993a; 12:10-18.

Hankin JR, Sloan JJ, Firestone IJ, Ager JW, Sokol RJ. A time series analysis of the impact of the alcohol warning label on antenatal drinking. Alcoholism: Clinical and Experimental Research 1993b; 17:284-289.

Hingson R, Alpert JJ, Day N, Dooling E, Kayne H, Morelock S et al. Effects of maternal drinking and marijuana use on fetal growth and development. Pediatrics 1982; 70:539-546.

Page 111

Ihlen BM, Amundsen A, Sande HA, Daae L. Changes in the use of intoxicants after onset of pregnancy. British Journal of Addiction 1990; 85:1627-1631.

Masis KB, May PA. A comprehensive local program for the prevention of fetal alcohol syndrome. Public Health Reports 1991; 106:484-489.

May PA. Research issues in the prevention of fetal alcohol syndrome (FAS) and alcohol-related birth defects (ARBD). Prevention Research on Women and Alcohol. E. Taylor, J. Howard, P. Mail, M. Hilton (eds.). Washington, DC: U.S. Government Printing Office, in press.

May PA, Hymbaugh KJ, Aase JM, Samet JM. Epidemiology of fetal alcohol syndrome among American Indians of the Southwest. Social Biology 1983; 30:374-387.

Midanik LR, Clark WB. The demographic distribution of US drinking patterns in 1990: Description and trends from 1984. American Journal of Public Health 1994; 84:1214-1222.

Miller BA, Downs WR, Testa M. Interrelationships between victimization experiences and women's alcohol use. Journal of Studies on Alcohol 1993; 11 (Supplement):109-117.

National Institute on Alcohol Abuse and Alcoholism. Alcohol Epidemiologic Data Directory, June 1994. Washington, DC: Alcohol Epidemiologic Data System, NIAAA/Cyrus Corporation, 1994.

National Institute on Drug Abuse. NIDA survey examines extent of women's drug use during pregnancy. NIDA Media Advisory. Rockville, MD: NIDA, 1994.

Plant M, Sullivan FM, Guerri C, Abel EL. Alcohol and pregnancy. Health Issues Related to Alcohol Consumption. P. M. Verschuren (ed.). Brussels: International Life Sciences Institute, 1993.

Serdula M, Williamson DF, Kendrick JS, Anda RF, Byers T. Trends in alcohol consumption by pregnant women: 1985 through 1988. Journal of the American Medical Association 1991; 265:876-879.

Smith IE, Lancaster JS, Moss-Wells S, Coles CD, Falek A. Identifying high-risk pregnant drinkers: Biological and behavioral correlates of continuous heavy drinking during pregnancy. Journal of Studies on Alcohol 1987; 48:304-309.

Streissguth AP, Grant TM, Barr HM, Brown ZA, Mayock DE, Ramey SL et al. Cocaine and the use of alcohol and other drugs during pregnancy. American Journal of Obstetrics and Gynecology 1991; 164:1239-1243.

Tolo K, Little RE. The epidemiology of alcohol consumption and pregnancy. Gender and Alcohol. R. W. Wilsnack and S. C. Wilsnack (eds.). New Brunswick, New Jersey: Rutgers Center of Alcohol Studies, in press.

Waterson EJ, Murray-Lyon IM. Alcohol, smoking and pregnancy: Some observations on ethnic minorities in the United Kingdom. British Journal of Addiction 1989; 84:323-325.

Waterson EJ, Murray-Lyon IM. Preventing alcohol related birth damage: A review. Social Science and Medicine 1990; 30:349-364.

Weiner L, Morse BA, Garrido P. FAS/FAE: Focusing prevention on women at risk. International Journal of the Addictions 1989; 24:385-395.

Williams GD, DeBakey SF. Changes in levels of alcohol consumption: United States, 1983-1988. British Journal of Addiction 1992; 87:643-648.

Wilsnack SC. Alcohol Use and Alcohol Problems in Women. Psychology of Women's Health: Progress and Challenges in Research and Application. A. L. Stanton and S. J. Gallant (eds.). Washington, DC: American Psychological Association, in press, a.

Wilsnack SC. Patterns and trends in women's drinking: Recent findings and some implications for prevention. Prevention Research on Women and Alcohol. E. Taylor, J. Howard, P. Mail, M. Hilton (eds.). Washington, DC: U.S. Government Printing Office, in press, b.

Wilsnack SC, Wilsnack RW, Hiller-Sturmhofel S. How women drink: Epidemiology of women's drinking and problem drinking. Alcohol Health & Research World 1994; 18:173-181.