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NOFAS-UK releases a film on FASD awareness for midwives
NOFAS-UK has just released a 26-minute film which explores the risks associated with drinking alcohol during pregnancy.
The film follows three women over the course of a day to explore how each understands FASD: Joy, a community midwife of 30 years; Samantha, a birth mother to a child with undiagnosed FASD; Melissa,a pregnant woman who is drinking low levels of alcohol.
In terms of screening during pregnancy, the film comments:
There are assessment tools such as the AUDIT-C, T-ACE, and TWEAK. These can aid midwives when asking difficult questions. Though many believe that it is the relationship between midwives and women that becomes the best tool for acquiring accurate information.
“Midwives should feel confident in their own skills and abilities and be able to think ‘I talk with women everyday and I know my clients and I know how to ask them questions about their lifestyle and that it’s my role to give them information. In order to give them the information they need, I might have to ask them difficult questions.’ “
The film can be viewed on the NOFAS-UK website. Also check out the resources for pregnant women.
Project Choices program focuses on alcohol, sex and birth control for young women
The Project Choices program has been offered in Winnipeg, Manitoba since September 2010. Originally based on a program developed in the United States in the 1990s, it has continued to evolve to meet the needs of the community.
You can check out the recently launched website which includes FAQs and a great Links section. While the website is targeted at young women, it also includes information for service providers.
Project CHOICES is an FASD prevention program that works with girls/women of any age who are not currently pregnant, drink alcohol, and are sexually active. The goal of the program is to reduce the risk of an alcohol-exposed pregnancy through choosing healthy behaviours around alcohol and birth control use. Program partners include Klinic Community Health Centre, Norwest Co-op Community Health, and Healthy Child Manitoba.
Learn more about Project Choices in Canada and the research evidence to support the program in previous posts:
- College Binge Drinking and FASD Prevention (February 28, 2011)
- More on Project CHOICES (September 24, 2010)
- Project CHOICES Comes to Canada (September 14, 2010)
Pilot study results suggest that meconium screening may not deliver on its promise
Meconium, the first stools of a newborn baby, can be tested following birth. Amongst other things, it can tell us about prenatal exposure to alcohol.
While it is a far from perfect test (e.g., it only tells us about alcohol use in the second and third trimesters of pregnancy, it is subject to false positives, and a positive test does not equal a diagnosis of FASD), it is believed by some that if meconium testing was to be routinely implemented that it would help with early diagnosis of FASD which would then in turn help with addressing some of the negative consequences of FASD later in life such as difficulties at school or problems with the law. (Meconium testing does not prevent FASD or help to reverse biological effects of alcohol consumption during pregnancy).
A recent study published in the journal Alcohol explores whether women would willingly participate in a neonatal screening program which involves meconium testing. The pilot screening project was conducted in a high-risk obstetric unit in a regional Ontario hospital.
First, the researchers conducted anonymous testing where mothers agreed to have meconium collected from their baby as long as the test results were not connected to individuals. Then, in order to compare, a second group of mothers were asked to participate in an open screening program. The results were significantly different in terms of participation and the rates of a positive test for alcohol exposure.
The participation rate in the screening program was significantly lower than when testing was conducted anonymously (78% vs. 95%) and the positivity rate was 3% in contrast to 30% observed under anonymous conditions. The researchers conclude that the majority of mothers who consumed alcohol during pregnancy refused to participate in a screening program.
The researchers comment on how these outcomes are likely due to embarrassment, guilt, and fears of stigma and child apprehension. One of the suggested ways of resolving this is to eliminate the need for maternal consent to the test. This is an extremely murky ethical area and not likely one to build trust between health care providers and women giving birth (I mean, how would you like it for a random nurse or doctor conducted tests on your child without you knowing about it? Is that really in the “best interests of a child”?).
But it also doesn’t get at the whole issue of how some mothers, regardless of whether they drank alcohol or not during pregnancy, may not be interested in this particular application of technology which is intent on scrutinizing their every move, especially when there is no evidence of spectacular outcomes from the test (FASD is, at present, incurable). In this pilot study, there was one positive case identified by the screening. This led to the identification of motor development delays at 6 months and referrals for further assessment – but it’s not even clear if these delays were related to prenatal alcohol exposure or other factors.
For more on meconium screening, see earlier posts:
- Testing for Fetal Exposure to Alcohol (November 15, 2011)
- The Ethics of Meconium Screening (October 3, 2011)
- Thinking About Meconium Screening (September 28, 2010)
References
Zelner, I., Shor, S., Lynn, H., Roukema, H., Lum, L., Eisinga, K., Koren, G. (2012). Neonatal screening for prenatal alcohol exposure: Assessment of voluntary maternal participation in an open meconium screening program. Alcohol, 1-8. Epub 22 March 2012. doi:10.1016/j.alcohol.2011.09.029
Zelner, I., Shor, S., Lynn, H., Roukema, H., Lum, L., Eisinga, K., Koren, G. (2012). Clinical use of meconium fatty acid ethyl esters for identifying children at risk for alcohol-related disabilities: the first reported case. Journal of Population Therapeutics and Clinical Pharmacology, 19(1):e26-31. (Free full-text)
Asking “Do you drink alcohol?” is not enough
The American College for Obstetricians and Gynecologists is an organization of over 57,000 obstetricians and gynecologists. In 2011, the College did an extensive assessment of the needs of its membership to address at-risk drinking of all women, not only pregnant women. This new website contains tools that were collected and developed in response to this assessment.
The website is designed to support health care providers in screening and brief intervention and offers a cell phone app, downloadable patient information sheets, current news articles, and treatment referral information. Some examples of tools you can find include:
- iPhone app for identifying and intervening with women who drink at high-risk levels
- ACOG committee opinion: At risk drinking and alcohol dependence: Obstetric and gynecologic implications
- FAQs
The website feels a little cluttered (not all the resources are equally good) and not as dynamic and clean as I would like, but it’s great to see the interest in women and alcohol by the College and not just in relation to pregnancy.
Damskaya or "Ladies Vodka" (image via ABC News)
Russia is considered to be a country with one of the highest levels of alcohol consumption in the world. (See the World Health Organization’s Alcohol and Health profile for Russia here). And in a country where rates of alcohol consumption are increasing in general, and in women and youth in particular, it’s interesting to consider the context of FASD prevention.
One report indicates a sharp increase in average alcohol consumption of 80% between 1990 and 2005. Other reports show increasing consumption among women and young people and suggest that alcohol marketing directed at women is becoming more common. (For more on the latter, you might want to check out the 2008 Reuters article New ladies’ vodka gives doctors a headache which discusses the release of Damskaya or “Ladies” vodka, targeted at upwardly mobile women and “designed to be sipped with salad after a workout in the gym.”)
The actual rate of FASD in Russia is unknown (not surprising, as official diagnosis is a problem pretty much everywhere) so estimates vary depending on the sample being considered. In a sample of children in orphanages for children with mental health problems in Moscow in 2006, 7.9% of the children were identified as having FASD (186 children out of 2,352). In 2005, in a high risk maternity hospital, the FASD rate was 3.6/1000 live births (which was up from 1.2/1000 in 2004).
A study published last fall by Tatiana Balachova and her colleagues examined drinking patterns among pregnant and non-pregnant women of childbearing age in Russia. They interviewed 648 pregnant and non-pregnant women of childbearing age (18-44) in 7 public women’s clinics in St Petersburg and the Nizhny Novgorod region. They found that:
- 89% of non-pregnant women reported consuming alcohol and 65% reported binge drinking in the past 3 months (binge drinking was defined as 4 or more drinks)
- Women who might become pregnant consumed alcohol similarly to women who were not likely to become pregnant
- There was a significant decline in drinking after women learned they were pregnant – down to 20% of women consuming alcohol
- A high prevalence of binge drinking among women who might become pregnant (e.g., using contraception inconsistently) or who were trying to conceive
Since conducting this survey in 2004-2005, Tatiana Balachova and her colleagues have developed educational materials and online training programs for health care providers and the general public and conducted training for physicians around FASD prevention.
In an interview with Balachova, the reporter commented: “Balachova faced cultural and institutional obstacles to implementing the programs, such as lack of motivation, time constraints of physicians, inadequate training of staff and even the belief that physicians shouldn’t conduct brief interventions. She also encountered misconceptions such as the notion that harm is only caused if parents are intoxicated at conception and the idea that “normal” women don’t drink and are not at risk.”
You can take a look at some of the educational materials they’ve developed on this website (in Russian) and an overview of this work here.
And to wrap up this post, I thought I would mention a resource that was just pointed out to me. Some of you might be familiar with the book Best I Can Be: Living with Fetal Alcohol Syndrome or Effects by Liz Kulp. Well, supporters of the book have translated the book into Russian and Ukrainian and the book can be downloaded for FREE as an e-book from the Braided Cord website.
References
Balachova, T., Bonner, B., Chaffin, M., Bard, D., Isurina, G., Tsvetkova, L. and Volkova, E. (2012), Women’s alcohol consumption and risk for alcohol-exposed pregnancies in Russia. Addiction, 107: 109–117. doi: 10.1111/j.1360-0443.2011.03569.x
Balachova, T. and Varavikova, E. (2008). Preventing FAS/FASD in Russian Children. 1st Central and Eastern European Summit on Preconception Health and Prevention of Birth Defects. August 27-30, 2008. (powerpoint presentation)
Emerging research on biomarkers and nutritional supplements
Egg yolks are considered a good source of choline, a nutrient that may reduce the harms of prenatal alcohol exposure
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) in the United States has recently released a 6-page summary called Fetal Alcohol Spectrum Disorders: Understanding the Effects of Prenatal Alcohol Exposure. It summarizes the latest research on the full spectrum of alcohol-related developmental disorders, new diagnostic tools that can detect these disorders, and promising interventions and treatment options.
Of particular interest to a prevention audience is the very emerging research on nutritional supplements and some more info on the latest biomarkers research.
The authors comment on animal studies exploring the role of certain nutrients, such as zinc, folate, and choline, in helping to protect a developing fetus from the harms of alcohol. Choline appears to be the most researched nutrient. Some animal studies are showing that newborns given choline supplements and exposed to alcohol had less alcohol-related birth weight reductions, physical defects, and changes in behavior. It also appears that being administered choline postnatally could improve symptoms such as alcohol-related memory problems later in adulthood.
The subject of biomarker screening, in particular fatty acid ethyl ester (FAEE) screening in newborn meconium (a baby’s first stools), is something that I’ve mentioned several times before on this blog. Biomarkers are basically chemicals in fluids or tissues that change as a result of prenatal alcohol exposure. While blood and urine can be tested for alcohol, they only tell us about alcohol use close to the time of consumption. Other biomarkers that are currently being investigated include:
- Phosphatidylethanol (PEth) —PEth is a product of alcohol metabolism that may indicate heavy maternal drinking levels. It shows up in a newborn’s blood.
- Fatty acid ethyl ester (FAEE) screening—FAEEs, which are products of alcohol metabolism, are present in babies exposed to alcohol late in pregnancy, and they build up in hair and stool of the fetus and can be measured in the meconium or hair of the newborn.
- microRNA screening—Particular types of microRNA, or non–protein-coding RNAs, may change as a result of prenatal alcohol exposure
- Protein (or proteomic) screening—This method looks for a possible pattern of proteins that may change in the presence of alcohol.
For more on nutritional supplements, see an earlier post FASD Prevention and Prenatal Nutrition (March 29, 2011).
For more on biomarkers and meconium screening, see earlier posts:
- Testing for Fetal Exposure to Alcohol (November 15, 2011)
- The Ethics of Meconium Screening (October 3, 2011)
- Thinking About Meconium Screening (September 28, 2010)
Stylish new campaign from Norway
The Norwegian Directorate for Health has a new alcohol and pregnancy campaign which includes YouTube videos, brochures, posters, FAQs, and a series of videos with experts on alcohol and pregnancy.
The expert videos are with midwives, pediatricians and psychologists and they talk about a range of issues related to working with pregnant women and alcohol. Topics include: initiating early conversations with pregnant women about alcohol and addressing concerns of “I drank before I knew I was pregnant.” The campaign also encourages women to change their drinking habits before they get pregnant.
Many of the materials are available for free download from the website and some are available in multiple languages (e.g., Bokmål, Nynorsk, Sami, English, Polish and Spanish.)
The message at the end of the videos below translates (with the help of Google Translate) as: Give your child the best start. Do not drink alcohol during pregnancy.
I also found this article interesting (again, with the help of Google Translate). It talks about the pressures that many pregnant women experience to drink before they have told others they are pregnant. According to a survey by the Norwegian Health Directorate, 1 in 4 pregnant women find it difficult to say no to alcohol at company parties or beer on Fridays. “No thanks” apparently just doesn’t cut it.
The article offers other solutions such as accepting a glass of wine or beer and then not drinking it; saying “no thanks” and asking for something else like a Coke; telling people that you are driving or on antibiotics; or drinking a mocktail. The article also encourages readers not to be pushy hosts themselves – if someone says ‘no’, accept it at face value, regardless of whether they are pregnant or not.
I don’t think I’ve seen such frank discussion of how alcohol is so tightly entwined into our culture and the pressures this places on many pregnant women – I like it a lot!
YouTube videos for physicians on screening for alcohol use in pregnancy
The Best Start Resource Centre has just uploaded many of their videos to You Tube, including its 2005 video Effective Practices in Screening for Alcohol Use in Pregnancy .
This video, designed as part of a training module, informs physicians about alcohol use and abuse in pregnancy and supports physicians in appropriate screening and assessment of their pregnant patients with tools and resources.
At less than 15 minutes (it’s split into two parts), it’s worth looking at – there’s some really great examples of what NOT to do and suggestions for ways of broaching and discussing alcohol with pregnant women. (You can also marvel at how training materials for 2005 already look dated to viewers in 2011…)
Check out other alcohol and pregnancy resources from Best Start here.
Media coverage of meconium testing fails to raise important questions
Last week, CBC News reported on a study currently happening in PEI (Baby poop study tracks alcohol use, November 8, 2011). This study is testing the meconium (the first stools of a baby) of every baby born in the province to try and get a sense of the prevalence of alcohol-exposed pregnancies.
According to the article, the study is intended to provide the “first accurate data on the number of babies being affected by Fetal Alcohol Syndrome on P.E.I.” Of course, we know that is not true. Meconium testing for alcohol use during pregnancy only tells us about alcohol use in the second and third trimesters of pregnancy. Like all tests, it has a tendency to produce false positives and negative results. Further, positive test results do not equal a diagnosis of FASD in an infant – one study suggests that 40% of fetuses exposed to moderate to high amounts of alcohol during pregnancy may develop FASD (Koren, Huston, and Gareri, 2008).
The article also reports that researchers did not require consent from parents to do the test but did not provide a rationale for this.
In a recent post (The Ethics of Meconium Screening, October 3, 2011), I mentioned a 2 1/2 hour webinar on meconium testing held at the 12th Annual Fetal Alcohol Canadian Expertise (FACE) Research Roundtable. As well as being able to view the entire webinar on the Canadian Association of Pediatric Health Centres website, you can listen to a podcast of the webinar or read a summary paper recently published in the Journal of Population Therapeutics and Clinical Pharmacology.
Bernard Dickens, one of the speakers at the webinar, also just published a paper on legal and ethical issues surrounding meconium testing which I think is worth reading – often, issues like meconium testing become viewed primarily as public health issues and I think there are some civil rights issues in this instance that are being neglected. For example:
- Who owns meconium?
- How can we address the assumption by many parties that meconium test results, which tell us about potential alcohol use during pregnancy, are not by themselves a child protection concern?
- If universal testing is considered too costly, is it even possible to conduct targeted testing of “high risk” groups in the population in a way that that does contribute to negative stereotyping or racial/ethnic profiling? (Let me be blunt: are Aboriginal groups being consulted with all these ongoing investigations into how meconium testing can be incorporated into newborn care?)
On the issue of testing a baby’s meconium without maternal consent, Dickens comments:
“The fact that meconium may lawfully be tested without a mother’s consent raises the issue of whether it is ethical to employ a power allowed by law (since not everything that is legal is ethical), and whether mothers should at least be informed that this test will be conducted. Where it is conducted for anonymous prevalence studies, no disclosure may be required, because the test result is not relevant to the individual child’s care.
If testing is undertaken to provide clinical evidence of children’s prenatal exposure to alcohol, however, some neonatal facilities not seeking consent do inform mothers that their newborns’ meconium will be tested. They may also respect mothers who say that they object to such a test, by not conducting it. This is legally questionable, however, if the tests are proposed for the particular children’s care, since parents are legally required to provide or consent to medical services, including tests, that are in their children’s interests.”
References:
Dickens, B.M. (2011). Legal and Ethical Considerations in Meconium Testing for Fetal Exposure to Alcohol. Journal of Population Therapeutics and Clinical Pharmacology, 18(3):e471-e474. (Free full text here).
Koren G, Hutson J, Gareri J. (2008). Novel methods for the detection of drug and alcohol exposure during pregnancy: implications for maternal and child health. Clin Pharmacol Ther, 83(4):631-4.
Macleod, S. and Koren, G. (2011). Meconium Testing for Fatty Acid Ethyl Esters: A 2011 Status Report. Journal of Population Therapeutics and Clinical Pharmacology, 18(3):e500-e502. (Free full text here)
Kununurra : Lily Creek Lagoon by Peter Connolly
I first blogged about the Ord Valley Aboriginal Health Service FASD program back in January 2011 (see the post Getting Fathers Involved). Last week, an article called Ord Valley Aboriginal Health Service’s fetal alcohol spectrum disorders program: Big steps, solid outcome was published in the Australian Indigenous HealthBulletin. The author, Bridge, provides an overview of the program and reflects on successes and challenges as the first year draws to a close.
An FASD prevention program was initiated in August 2009 through the Ord Valley Aboriginal Health Service (OVAHS). OVAHS is a comprehensive primary health care (PHC) facility servicing Aboriginal people in the remote township of Kununurra and the surrounding communities. (Kununurra is situated in the far north east Kimberley region of Western Australia). The town has a population of approximately 7,500 people, and of those, approximately 50% are Aboriginal.
The program was developed to take a broad, holistic approach to working with women and their families. It also recognized the links between prenatal alcohol use, other drug taking behaviours and teenage sex/contraception issues. The program they developed targeted five groups:
- All Aboriginal women receiving prenatal care at OVAHS
- All Aboriginal women between the ages of 13 to 45
- OVAHS staff
- Local Aboriginal men
- Local, national and international interest groups and organisations.
The primary focus of the program is working with pregnant women. As part of their prenatal care, women receive FASD education, alcohol and other drug assessment and one-to-one counseling. Brief intervention, motivational interviewing and a three part antenatal assessment are key features of the program. When appropriate, these interventions are extended to include partners, families and the community as a whole. Information is also provided on contraception.
Contraception is viewed in the program as a cornerstone of FASD prevention. The author comments:
Dialogue with young women in the community revealed that their knowledge of puberty, menstruation, pregnancy and contraception varied, with a significant number reporting little knowledge of contraception in particular. Given the incidence of early alcohol use among young women (and its resultant impairment of judgement), and their attitudes and norms around consumption, the program has placed considerable emphasis on the promotion of alcohol awareness, contraception and safe sexual practices as part of all brief interventions.
One of the unique features of this program, I think, is the clear attempt to involve men in FASD prevention. Bridge says that men appear interested in FASD education for a variety of reasons. “The men also believe that Aboriginal culture, knowledge and stories rely heavily on oral tradition, and therefore memory, and that this is potentially lost if many of the next generation suffer neurological damage as a result of pre-natal alcohol exposure. Men within the local community are also aware that too many of their young men are leaving school early and with only basic education, and that rates of imprisonment are high among Aboriginal men. As such the local men have voiced concern that FASD could be a contributing factor, especially as Aboriginal people currently make up 21% of the total number of Australian prisoners, yet only comprise 2.5% of Australia’s population.”
Results from the program clearly demonstrate the role that men/fathers have in supporting women to make alcohol-free choices:
In some families, women report that men hold the power-base and as such strongly influence the choices made regarding alcohol use in their pregnancies. Through conversation with antenatal clients, a number of women identified pressure from their partners as being significant in determining drinking behaviours during pregnancy. The women reported they would like to stop drinking, but were often pressured to stay with their partners in the ‘drinking circle as a show of family loyalty and their commitment and faithfulness to the relationship. Some female clients also report that to remove themselves from this social circle and ‘sit’ with non-drinking family members or friends, or spend time doing activities such as fishing potentially results in relationship problems, arguments or even violence. The role men play in the decision making of some clients was not initially anticipated, but it was recognised early on that the success of the program lay in part in the inclusion and education of men.
You can read the full-text of the article here.
Read more on FASD prevention in Western Australia:
Bridge, P. (2011). Ord Valley Aboriginal Health Service’s fetal alcohol spectrum disorders program: Big steps, solid outcome. Australian Indigenous HealthBulletin 11 (4). Free full-text.
GG makes historic visit to Kimberley town (The West Australian, August 11, 2011)
Ch. 3: From community crisis to community control in the Fitzroy Valley. In The Aboriginal and Torres Strait Islander Social Justice Commissioner. (2011). Social Justice Report 2010. Australian Human Rights Commission.
CTIS applauds new efforts to prevent FASD in rural Australia (December 15, 2010)
Marulu: The Liliwan Project (The George Institute for Global Health)
