Women, Alcohol, Pregnancy, FASD Prevention Nancy Poole, BCCEWH and CanFASD Research Network

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Women, Alcohol, Pregnancy, FASD Prevention Nancy
Poole, BCCEWH and CanFASD Research Network

NANCY POOLE Director , BC Centre of Excellence
for Womens Health
CPHA June 2014
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• Issues

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Issue Scope of FASD prevention is expanding
beyond alcohol use
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 ........
RISK OF CHILD BEING BORN WITH FASD



ALCOHOL
PREGNANCY
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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?
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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.
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Why do women drink alcohol during pregnancy?

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)

Coalescing on Women and Substance Use
www.coalescing-vc.org
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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 dont feel fully
  prepared to discuss substance use with women

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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.
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Issue Light drinking in pregnancy
Evidence is inconsistent at low-moderate levels
of consumption.
Some studies suggest NO EFFECT of light-moderate
drinking during 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 (N10,534 - 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
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Some studies show a J or U shaped curve
suggesting a protective effect from light drinking
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Issue Light drinking in pregnancy
Evidence is inconsistent at low-moderate levels
of consumption.
Some studies suggest ADVERSE EFFECTS of
light-moderate drinking during 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
Studies define light drinking differently which
contributes to confusion.
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Issue Messaging around light drinking

• 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.
Coalescing on Women and Substance Use
www.coalescing-vc.org
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Recent research on messaging
Discussing ambiguity with women - Helpful or not?
Public health guidelines "The safest choice is
to not drink at all while pregnant, planning to
become pregnant or before breastfeeding Importan
ce 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 messages
persuasiveness. (France et al., 2013, p.8)
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• Promising Developments

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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

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

• Examples
• Development of health education materials
  (pamphlets, posters)
• Awareness campaigns
• Low risk drinking guidelines
• Materials for facilitators of girls empowerment
  groups

http//www.ccsa.ca
http//www.womenspopulationhealth.ca/womenandalcoh
ol
www.bcliquorstores.com
http//girlsactionfoundation.ca
http//www.skprevention.ca/
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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

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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 1825 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)
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Need for support on alcohol beyond pregnancy, to
support womens health, and their role as mothers

• Report from SAMHSA 2009
• Rapid resumption of substance use noted in first
  3 months postpartum

Substance 3rd Trimester 3 Months Postpartum
Alcohol 6.2 31.9
Binge drinking 1 10
Cigarettes 13.9 20.4
Marijuana 1.4 3.8
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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.

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

• 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 womens
  healing from illicit drug abuse.

From Stillettos to Mocassins http//www.youtube.c
om/watch?v1QRb8wA2iHs
Colleen Anne Dell, Research Chair in Substance
Abuse, University of Saskatchewan www.addictionres
earchchair.ca
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Wide range of people are interested in having
empowering conversations
Peer Support/Mentors
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SUMMARY

• Putting our efforts into a range of alcohol
  policy, health promotion and prevention efforts
  seems wise
• awareness building and community development
• brief alcohol intervention with all women
• holistic support with pregnant women with alcohol
  and related health and social concerns
• support for new mothers and children, and
• community alcohol policy

Four Levels of FASD Prevention (Poole, 2008)
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Selected Publications from the CanFASD Prevention
Network Action Team
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Contact BC Centre of Excellence for Women's
Health www.bccewh.bc.ca Coalescing on
Women and Substance Use www.coalescing-vc.org Cana
da FASD Research Network www.canfasd.ca Girls,
Women, Alcohol, and Pregnancy Blog http//fasdprev
ention.wordpress.com

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