Women, Alcohol, Pregnancy, FASD Prevention

Nancy Poole, BCCEWH and CanFASD Research Network

CPHA CPHA June 2014June 2014

NANCY POOLE Director , BC Centre of Excellence for Women’s Health

Issues

ISSUE: Scope of FASD prevention is expanding beyond alcohol use

+ =+ALCOHOL PREGNANCY

RISK OF CHILD BEING BORN WITH FASD

GENETICS

AGE

OTHER SUBSTANCE USE

NUTRITIONAL STATUS

ACCESS TO PRENATAL CARE

STIGMA

RACIAL DISCRIMINATION

PAST AND CURRENT EXPERIENCES OF

VIOLENCE AND ABUSE

ACCESS TO CONTRACEPTION

CHILD WELFARE AND MOTHERING POLICIES

........

ISSUE: Greater understanding of diversity of women at risk

Many diverse groups of women are more likely to consume alcohol during pregnancy, including women who:

• are older (over 30) • have high income or who are

unemployed or living in poverty • are in an abusive relationship• use other substances• are depressed • are coping with trauma• have a partner who drinks

heavily• are coping with the

intergenerational effects of colonization

(Skagerstróm et al, 2011; Niccols et al, 2009; Best Start, 2003; Bakhireva et al, 2011)

‘Middle class’ mothers as an overlooked risk group?

The story of the highest risk mothers

Study of Birth Mothers of 160 children with FAS Of the 80 interviewed:

• 100% seriously sexually, physically or emotionally abused

• 80% had a major mental illness

• 80% lived with men who did not want them to quit drinking

Astley, S. J., Bailey, D., Talbot, C., & Clarren, S. K. (2000). Fetal Alcohol Syndrome (FAS) Primary Prevention through FASD Diagnosis II: A comprehensive profile of 80 birth mothers of children with FAS. Alcohol and Alcoholism, 35(5), 509-519.

Why do women drink alcohol during pregnancy?

Coalescing on Women and Substance Use | www.coalescing-vc.org

1. Women are unaware they are pregnant.

2. Women are unaware of the extent of damage alcohol can cause the fetus.

3. Women underestimate the harms alcohol consumption can cause because they know other women who drank during pregnancy and their children appear healthy.

4. Alcohol use is the norm in their social group and abstaining may therefore be difficult.

5. Women may be using alcohol to cope with difficult life situations such as violence, depression, poverty, or isolation.

6. Women may struggle with alcohol addiction. (Cismaru et al., 2010)

ISSUE: Barriers to discussing alcohol use with pregnant women

Women report that guilt, shame and fears of losing their children to child welfare authorities prevent them from getting the help they need with alcohol problems

Physicians report that they don’t feel fully prepared to discuss substance use with women

ISSUE: Lack of recognition and tailored support

Unless proactive, problem alcohol use in women is often not recognized or treated

Often health care providers use confrontational, proscriptive or substance-focused approaches, which can be ineffective in supporting paced and achievable change in substance use by women

The Risk Drinking Project was a national government initiative carried out from 2004 to 2010 in Sweden. The proportion of midwives who considered themselves to have very good or good knowledge in identifying patients with risky alcohol consumption increased from 72 to 92 per cent between 2006 and 2009.

Evidence is inconsistent at low-moderate levels of consumption.

ISSUE: Light drinking in pregnancy

Recent examples:

Kelly et al (2008, 2012, 2013) - No increased risk of clinically relevant behavioural difficulties, cognitive deficits at age 3, 5, and 7 (N=10,534 - 12,495); differences in scores between boys and girls

Humphriss et al (2013) - No effect of moderate (3-7 glasses/week) maternal alcohol consumption on balance at age 10;

Some studies suggest NO EFFECT of light-moderate drinking during pregnancy

Some studies show a ‘J’ or ‘U’ shaped curve suggesting a protective effect from light drinking

Evidence is inconsistent at low-moderate levels of consumption.

ISSUE: Light drinking in pregnancy

Recent examples:Andersen et al (2012) - Low to moderate

consumption of alcohol increased risk of spontaneous abortion substantially in first trimester (N= 92 719)

Feldman et al (2012) - Increased risks for physical features of FAS and growth deficiencies (reduced birth length and weight); dose-related effects, no evidence of safe threshold at lower amounts of alcohol use

Nykjaer et al (2014) Even at 2 units per wk or less, low birth weight and preterm birth

Some studies suggest ADVERSE EFFECTS of light-moderate drinking during pregnancy

Studies define ‘light’ drinking differently which contributes to confusion.

ISSUE: Messaging around ‘light drinking’

Coalescing on Women and Substance Use | www.coalescing-vc.org

While the risk from "light" consumption during pregnancy appears very low, there is no known threshold of alcohol use in pregnancy that has been definitively proven to be safe.

Individual-level factors such as nutrition, genetics, and other substance use can interact to affect outcomes.

Potential for misunderstanding drink sizes and actual alcohol content of various types of drinks

Compelling evidence from research on animals that even low doses of alcohol at any time during pregnancy can affect fetus

“No safe time. No safe amount. No safe kind.”

Discussing ambiguity with women - Helpful or not?

Recent research on messaging

Public health guidelines: "The safest choice is to not drink at all while pregnant, planning to become pregnant or before breastfeeding“

Importance of being honest and factual about the limits of research on alcohol during pregnancy suggested by some studies

“Credibility … was enhanced by acknowledging uncertainty about the risk to the fetus with low to moderate alcohol exposure. Rather than undermine an abstinence-based message, this information served as a clear rationale for the recommendation. An honest and scientific framing of the message and delivery by an expert source were also shown to minimize counterargument and strengthen the message’s persuasiveness.” (France et al., 2013, p.8)

Pro

misin

g

Develo

pm

en

ts

We have evidence for effectiveness of strategies at 4 levels Today - will focus

briefly on promising developments in:

Level 1 • Awareness and health

promotion

Level 2 • Brief Interventions• Dual-focused Interventions

(Alcohol + Contraception)• Preconception

Interventions

LEVEL 2 Discussion of alcohol use and related risks with all women of childbearing years and their support

networks

LEVEL 3Specialized, holistic support of pregnant

women with alcohol and other health/ social

problems

LEVEL 1 Broad awareness building

and health promotion efforts

LEVEL 4Support for new mothers and for child development

and assessment

SUPPORTIVE ALCOHOL

POLICY

Strategies that involve women, support networks, communities, service providers, health system planners, governments

Examples: Development

of health education materials (pamphlets, posters)

Awareness campaigns

Low risk drinking guidelines

Materials for facilitators of girls’ empowerment groups

ww

w.b

cliq

uors

tore

s.co

m

http://girlsactionfoundation.ca

http

://w

ww

.ccs

a.ca

Current Awareness Building

http://www.skprevention.ca/

http:

//w

ww

.wom

ensp

opul

ation

heal

th.c

a/w

omen

anda

lcoh

ol

There is evidence for a wide range of tools and interventions related to identification and brief support

Drink size and “alcohol literacy”

Routine screening

Screening for polydrug use (e.g., alcohol and tobacco)

Formal tools: CAGE, AUDIT, T-ACE, TWEAK and new tools such as 3 questions (Substance Use Risk Profile), indirect screening, and questionnaire based counselling at maternity care centres

Web- and computer-based interventions, telephone screening

Medical school training and continuing education

Evidence for collaborative preconception approaches

Project CHOICES Multi-site RCT - CHOICES intervention (motivational plus assessment feedback counseling intervention) vs. informational brochure

Reductions in AEP risk were significantly more likely among participants who received CHOICES than participants who received informational brochures.

The absolute risk reduction (the decrease in risk from baseline to follow-up of the intervention condition relative to a comparison condition) was 18% (Floyd et al., 2007; Ingersoll, Floyd, Sobell, Velasquez, & Project CHOICES Intervention Research Group, 2003)

Project BALANCE RCT - Tested among college women ages 18–25 at risk for AEP by comparing one 60-minute session (BALANCE) to an informational brochure condition

At a 4-month follow-up, 80% of participants who received BALANCE reported no past month AEP risk, compared to 65% of participants who received the informational brochure, representing a 15% absolute risk difference between conditions.(Ceperich & Ingersoll, 2011; Ingersoll, Ceperich, Nettleman, Karanda, Brocksen, & Johnson, 2005)

Project CHOICES Facilitator

Guide (via www.cdc.gov)

Need for support on alcohol beyond pregnancy, to support women’s health, and their role as mothers

Report from SAMHSA 2009

Rapid resumption of substance use noted in first 3 months postpartum

Substance

3rd Trimest

er

3 Months Postpartu

m

Alcohol 6.2% 31.9%

Binge drinking

1% 10%

Cigarettes 13.9% 20.4%

Marijuana 1.4% 3.8%

Guidelines for brief intervention are in place

Health professionals who routinely provide healthcare to women of childbearing age are uniquely positioned to deliver important information about the health risks around the use of alcohol, tobacco and other drugs.

In general, research evidence supports screening and brief interventions for alcohol misuse as efficacious and cost-effective in a variety of settings.

Avoiding ‘gender-exploitive’ approaches

Culturally safe approaches are being identified - perspectives of women with alcohol and drug problems

Colleen Anne Dell, Research Chair in Substance Abuse, University of Saskatchewanwww.addictionresearchchair.ca

In a recent study, Aboriginal women participating in treatment identified the RECLAIM principles as important for treatment providers to understand and apply when supporting Aboriginal women’s healing from illicit drug abuse.

From Stillettos to Mocassins http://www.youtube.com/watch?v=1QRb8wA2iHs

Wide range of people are interested in having “empowering conversations”

Supporting women

in childbearing years around

alcohol and related concerns

Doulas

Midwives

Physicians

Public Health Nurses

Acute Care

Nurses

Transition House

Workers

Social Workers

Pregnancy Outreach Workers

Addictions Counselors Mental Health

Service Providers

Nutritionists

Youth Support Workers

Tobacco Reduction

Coordinators

Aboriginal Service

Providers

Dental Hygienists

Family Support Workers

Early Childhood

Development Program Providers

FASD Key Workers

Peer Support/Mentors

Putting our efforts into a range of alcohol policy, health promotion and prevention efforts seems wise: 1.awareness building and community development2.brief alcohol intervention with all women 3.holistic support with pregnant women with alcohol and related health and social concerns 4.support for new mothers and children, and5.community alcohol policy Four Levels of FASD Prevention (Poole, 2008)

SUMMARY

Selected Publications from the CanFASD Prevention Network Action Team

ContactBC Centre of Excellence for Women's Health

www.bccewh.bc.ca

Coalescing on Women and Substance Use

www.coalescing-vc.org

Canada FASD Research Network

www.canfasd.ca

Girls, Women, Alcohol, and Pregnancy Blog

http://fasdprevention.wordpress.com

Our blog is a resource for learning about specific prevention topics as well as prevention work around the world, •68 posts were made over the 2013 year •The blog was viewed about 38,000 times in 2013, on average 3000 times per month, and on average 100 times per day•by people in 161 countries