A Systematic Review of International Guidelines for Addressing Alcohol Use Disorder in Pregnancy

Abstract

Despite well-documented harms of prenatal alcohol exposure, evidence-based treatment guidelines for alcohol use disorder (AUD) during pregnancy remain limited. We systematically reviewed international clinical practice guidelines to examine how they address the full cascade of AUD care during pregnancy, including diagnosis, engagement, treatment initiation, and retention. We searched over 40 clinical practice guideline databases (including PubMed and Guidelines International Network) and gray literature sources globally, identifying 1045 records. Using the Population, Interventions, Comparators, Attributes, Recommendation Characteristics (PICAR) framework, we evaluated guidelines from medical organizations in English-speaking nations addressing alcohol use and AUD management in pregnancy. Our final analysis included 18 guidelines from the United States, Canada, the United Kingdom, Australia/New Zealand, and the World Health Organization published from 2014 to the present. Two reviewers independently assessed each guideline using the Appraisal of Guidelines Research and Evaluation-Recommendations Excellence (AGREE-REX) framework to evaluate quality and risk of bias. We used narrative synthesis to summarize findings across key concepts and care cascade stages. Nearly all guidelines (94%) described risks of alcohol exposure and recommended counseling on cessation (89%), yet few extended beyond these early cascade stages. Only 44% mentioned medications for AUD (MAUD), and merely 17% discussed specific psychosocial treatments. Among guidelines addressing MAUD, only one cautiously supported use, while three explicitly recommended against it. Most guidelines (61%) ended treatment recommendations at referral to specialty care, with half limiting guidance to acute alcohol withdrawal management. Taken together, our findings reveal a stark misalignment between screening emphasis and treatment guidance. While guidelines consistently recommend universal screening and brief intervention, they provide minimal actionable frameworks for managing AUD throughout pregnancy. This gap leaves clinicians without evidence-based pathways for comprehensive AUD treatment during the prenatal period, highlighting an urgent need to strengthen both the evidence base and clinical guidance for AUD management in pregnancy.