Canadian Medicine

But be sure to ask nicely

Canada may be a little short of babies, but it’s got plenty of alcohol. Keeping the two separate has mostly been the task of GPs. But the says they’re falling short. Many pregnant women who drink are missed, says the SOGC, often because physicians are unwilling to ask questions about alcohol.

Doctors who don’t make alcohol use a routine question on all visits may be particularly unwilling to suddenly raise the issue during pregnancy, given the stigma associated with mothers who drink. And even those who do raise it may not be getting honest answers.

“Many physicians don’t even ask the question,” says Gideon Koren, director of the . “It’s not an easy thing to ask. We have a sad reality that physicians and other health professionals are not doing their job on that — namely that a lot of women are not asked and we do not identify the cases. At the end are kids who are very heavily affected.”

Dr Koren sat on an SOGC panel that has just issued . The guidelines offer an interesting snapshot of female drinking in Canada. Did you know that richer, more educated women, while less prone to binge drinking, are more likely to consume alcohol on a daily basis? Or that Quebec has the highest number of frequent women drinkers, by a wide margin? And where can you find the highest proportion of female teetotalers? You’d never guess - it’s Nunavut.

The SOGC takes a nuanced position on abstinence, recognizing that there’s just not enough evidence on the effects of low-level consumption. Essentially, the guidelines suggest you recommend abstinence in cases where you think you can make it stick, but avoid an all-or-nothing approach if you think it will scare the patient away.

Not scaring the patient away is the key thing in alcohol screening. While a record of maternal alcohol use has proven health benefits for the infant with a fetal alcohol spectrum disorder, its benefit to the mother is far less clear - it can lead to them losing custody of their kids and they know it.

A reliable lab test for long-term alcohol use is on the way, but it requires a six-inch lock of hair, and the SOGC acknowledges - perhaps a little wistfully - that it can’t really be applied to most patients. So we have to make do with self-reporting, and in that game, you catch more flies with honey.

Don’t ask patients how often they “use alcohol”, but instead enquire how frequently they “enjoy a drink”. Don’t tell them that by drinking they may have harmed their baby, but instead emphasize how cutting alcohol could help the baby’s health.

Don’t lowball. When prompting the patient on how many drinks she consumes a week, suggest a high number, because if you suggest a low one, the patient will be reluctant to incur your disapproval by admitting she drinks more than that.

While a warm, informal approach is generally best, validated alcohol dependence questionnaires like CRAFFT and TWEAK are useful. They avoid stigma because the patient tends to assume they’re routinely given in all pregnancies. (Or you could try our non-validated WYLAB questionnaire, which identifies at-risk patients with just one question: “Would you like a beer?”)

However you screen, the effort will pay dividends, says Dr Koren, who notes that 40% of pregnancies with high alcohol consumption result in a fetal alcohol spectrum disorder. About 3% of Canadian children are born with such a condition, with effects ranging from reduced IQ to violent aggression. In fact, says Koren, about half the inmates of Canada’s prisons are the offspring of hard-drinking mothers.
Owen Dyer