Preconception Resources: Increasing Awareness about Alcohol and Pregnancy

Click here to listen to the blog (3:18).

Preconception care is part of a continuum of support that promotes health during the reproductive years: for young girls and women who may be drinking alcohol without using effective contraception, those who are planning a pregnancy, and people in the interconception periods. Preconception care includes health promotion, education and counselling support that may have a focus on: protection (i.e., folic acid supplementation), avoiding harms (i.e., of alcohol use during pregnancy), and/or managing conditions (i.e., diabetes).

Discussing substance use in the preconception period can encourage reduction in alcohol and other substance use before and during pregnancy.  For example, pre-pregnancy alcohol use is a predictor of alcohol use during pregnancy and smoking fewer cigarettes pre pregnancy is a predictor of quitting smoking during pregnancy. Despite the importance of reaching women in the preconception period, efforts to do so have not always been prioritized by our health systems or in training to health and social service providers.

Two booklets designed to promote preconception care

In response to this gap in resources for people planning a pregnancy, the Centre of Excellence for Women’s Health and Canada FASD Research Network recently developed Thinking About Pregnancy: A Booklet to Reflect on Alcohol Use Before You are Pregnant. The booklet recognizes women’s agency and interest in learning more about supporting a healthy pregnancy. As such, we translated what we know as researchers into an accessible booklet for women that they can use independently or walk through with their partner(s) and healthcare providers when thinking about or planning a pregnancy.

Included in the booklet is information about standard drink sizes, why thinking about alcohol before you are pregnant is important, mocktail recipes and activities that help women reflect on what they like or dislike about drinking, what alternatives to alcohol use may be in their ‘toolbox’ and who is and will be by their side as they make change.

Project CHOICES in Manitoba offers another booklet that aligns with and complements Thinking About Pregnancy. While Thinking About Pregnancy is geared towards people who are planning a pregnancy, Project Choices: Alcohol and Sex Deserves a Discussion (available in French here) is geared towards youth and young adults who drink alcohol, are having sex, and want more information about alcohol use and birth control.

The booklet contains information on alcohol, contraception, and consent, and includes a number of self-reflection, goal setting and mindfulness activities that can help decrease alcohol use and/or increase contraception use and safe sex. Although the booklet can be used as a stand-alone resource, counsellors in the Project CHOICES program also use this booklet to educate participants about alcohol use, birth control, FASD, and support participants towards healthy goal-setting.

These booklets are designed to be accessible for girls, women and gender diverse individuals in reproductive years. Turning more attention to preconception care offers an opportunity to promote and empower health and wellbeing, while simultaneously contributing to the prevention of FASD.

Prevention Conversation: A Shared Responsibility

Click here to listen to the blog (2:47).

The Prevention Conversation is an online training program for health and social service providers to increase their knowledge about alcohol and other substance use in pregnancy and provide them with the skills to have safe and impactful conversations with women and people of child-bearing age and their support networks. The Prevention Conversation recognizes that these conversations are central to ensuring that families and communities know about the risks of drinking alcohol during pregnancy and feel supported in sharing the responsibility to reduce the harms of alcohol.

In Autumn 2022, the Canada FASD Research Network released an updated version of the online course to reflect the most recent research on FASD prevention and best meet the needs of diverse communities who are accessing prevention resources.

The updated course:

• Features best practice and updated evidence, wisdom, and language around alcohol use in pregnancy;
• Includes new modules on stigma reduction, alcohol and women’s health, and cultural safety and humility;
• Incorporates reflection questions that encourage course takers to reflect on how they can support women and people in the childbearing years in their local context and with the resources available to them;
• Includes new resources and content to support a range of practitioners working in different practice settings; and,
• Incorporates diverse peoples and knowledge systems through the addition of new content and artwork from Indigenous artists across Turtle Island. Art pieces from Indigenous artists, such as Cody Houle (see below), introduce every module, as a way to honour Indigenous knowledge systems and capture the spiritual, relational, and emotional connections to the modules. 

“Surrounded by Love” by Cody Houle introduces Module 5: Raising Awareness and Stigma Reduction. You can find his description of the piece in the online course.

The updated course follows the Four-Part Model of FASD Prevention to provide formative knowledge about alcohol and women’s health, FASD prevention and healthy beginnings, stigma reduction, cultural safety and humility, and trauma-informed practice. These modules can further facilitate open, respectful and non-judgemental conversations with women and their partners by a range of health and social service providers.

The Prevention Conversation is available online through the CanFASD e-store or can be delivered in-person in Alberta through the Prevention Conversation.

Staying Principled

Click here to listen to the blog (3:54).

In 2009 a group of women gathered in Victoria BC Canada to discuss how we would approach the development of a network on FASD prevention. We were researchers, policy advocates, service providers, community activists and those with Indigenous wisdom – all with a commitment to seeing and acting on how social determinants affect women’s health and substance use, and the ability for them influence the conditions of their lives.

Out of our discussion emerged a consensus on 10 fundamental components or principles for approaching FASD prevention from a women’s health determinants perspective. Now, in 2022, we have updated that consensus statement, so that those interested in FASD prevention are directed to new evidence and resources. The update is a testament to the soundness of the original principles and to the ever-growing expertise of the network participants and international partners. We hope this will empower those working on FASD prevention to continue to use and build upon this principle-based approach.

The principles foundational to approaching FASD prevention are:

Respectful – Grounding prevention initiatives in respectful relationships is vital to reduce stigma and discrimination.

Relational – It can be a transformative experience for women who use substances to experience care that aligns with their needs, views them as a whole person, and offers respect, understanding, and authentic collaboration.

Self-Determining – Health care and other support systems can facilitate self-determined care by supporting women’s autonomy, decision making, control of resources, and including exercise of their reproductive rights.

Women+ Centred – Women+ centered care moves beyond a fetus/child-centered approach, and focuses on fostering safety and empowerment when providing support to women and gender diverse individuals who are pregnant or parenting.

Harm Reduction Oriented – A harm reduction oriented approach focuses on safer substance use but also on reducing broader harms, including retaining or regaining custody of children, access to adequate and stable housing, and the challenges of poverty, food insecurity, and intimate partner violence.

Trauma- and Violence-Informed – Trauma- and violence-informed services integrate awareness of the impacts of trauma on health into all aspects of service delivery including wellness support and prevention of secondary trauma.

Health Promoting – Holistic, health promoting responses to the complex and interconnected influences on women’s health and substance use are vital to FASD prevention.

Culturally Safe – Respect for individuals’ values, worldviews, and preferences in any service encounter is important, as is respect for and accommodation of a woman’s desire for culturally-specific healing.

Supportive of Mothering – FASD prevention efforts must recognize women’s desire to be good mothers and the importance of supporting women’s choices and roles as mothers.

Uses a FASD-informed and Disability Lens – Uses strengths-based responses, makes person-centered accommodations, and ensures equity of access to health and social services.

We hope you will find the Consensus Statement with these principles and supporting sources – journal articles, reports and infographics – an inspiration for action.

Every Moment Matters – An evidence-based FASD prevention campaign for Australia

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Every Moment Matters is a nation-wide health promotion campaign launched in Australia which shares the latest evidence-based information about alcohol during pregnancy and breastfeeding. See www.everymomentmatters.org.au/.

The messages

The messages about alcohol use in pregnancy and FASD include:

• Every moment matters when it comes to alcohol – whether you are planning a pregnancy, currently pregnant or breastfeeding.

• Planning a pregnancy is an exciting time. It’s also a great opportunity to go alcohol-free. Make the moment you start trying the moment to stop drinking alcohol.
  • The “planning a pregnancy” section includes
    • information about how alcohol affects fertility, the risk for miscarriage, and how the placenta is not a barrier to alcohol
    • ideas for action, when sharing information with friends, and finding help

• All parents want to give their baby the best start in life, which is why it’s important not to drink any alcohol during pregnancy.
  • The “currently pregnant” section includes
    • information about how alcohol passes directly to the developing baby and can damage their brain, body and organs (FASD)
    • ideas for action to garner support from partners friends and family and for talking to a doctor, midwife or obstetrician

• When breastfeeding, not drinking alcohol is safest for the health of your baby.
  • The “when breastfeeding” section includes
    • information about how alcohol enters breastmilk, noting how when there is alcohol in one’s blood, it is also in their breastmilk
    • strategies to avoid exposure when a choice is made to drink alcohol while breastfeeding

All sections of the website contain many helpful facts about alcohol and pregnancy and breastfeeding, how women can make a change in alcohol use, and how to support someone who is pregnant or planning a pregnancy. And there are links to a multitude of resources: www.everymomentmatters.org.au/resources/

The underlying research

This campaign has the most solid background research of any undertaken to date. The Foundation for Alcohol Research and Education (FARE) commissioned research to ground the campaign that involved:

• A literature review and review of previous campaigns implemented in countries around the world, in order to establish best practice approaches to a campaign such as this.
• Research to understand attitudes, perceptions of risk, and understanding of the issues by people in Australia, to identify potentially effective messages and framing of messages. This research included women who were pregnant, planning a pregnancy (in the next 2 years) or who might become pregnant, through an online survey, virtual focus group discussions, online journey mapping forums and virtual in-depth interviews.

Very comprehensive findings from this research guided the creation and testing of messaging for the campaign so that the messages would ‘grab attention’, contain information that was personally relevant to various segments of the population and be persuasive so that women would avoid alcohol during pregnancy.

Learn more about the research and its impact

The sponsors of the campaign, FARE, are hosting a webinar on Dec 8^th (in Australia) entitled Behind the Scenes of Every Moment Matters where they will explore some of the key elements of this ground-breaking national health promotion campaign. Members of the campaign team will share insights into the formative research, message testing, creative approach, media strategy, engagement of health professionals in the campaign, and its impact to date.

This event is for people working in health promotion, public health policy, social marketing, the alcohol and other drugs sector, behaviour change, or evaluation design. 

See https://www.eventbrite.com.au/e/behind-the-scenes-of-every-moment-matters-tickets-439430427237

Actionable research! Reflecting on 5 years of FASD prevention research

Click here to listen to the blog (2:37).

Last month, the Journal of Fetal Alcohol Spectrum Disorder (FASD) released a special collection of articles about FASD prevention, diagnosis, intervention and support. The journal issue features the work of Canada Fetal Alcohol Spectrum Disorder Research Network staff, Research Leads, Family Advisory Committee (FAC) members, Adults with FASD Expert Collaboration Team (AFECT) members, trainees, board members, and community partners and collaborators. 

As part of the special issue, researchers from the Prevention Network Action Team contributed an article entitled At a Juncture: Exploring Patterns and Trends in FASD Prevention Research from 2015 – 2021 Using the Four-Part Model of Prevention. This article leverages off our annual annotated bibliographies, to identify trends in FASD prevention research over the six-year period.

From 2015 – 2020, n = 532 articles were identified that addressed:

1. the prevalence and influences on alcohol use during pregnancy, 
2. interventions at each of the Four-Part Prevention Model, and 
3. systemic, destigmatizing, and ethical considerations. 

The majority of the research was from the United States (n = 216), Canada (n = 91), the United Kingdom (n = 60), and Australia (n = 58).

While the literature continues to have a heavy focus on the prevalence and influences on alcohol use during pregnancy, a trend could be seen towards research on evidence-based interventions which support positive health outcomes for women and their children.

• Across both Level 1 and Level 2 prevention, there was an emphasis on the role of technology and its importance in disseminating education and messaging about alcohol use in pregnancy and FASD. 
• Attention to Levels 3 and 4 demonstrated the importance of multi-service, trauma-informed, relational, and holistic approaches in supporting women and their children. 
• While women’s voices were increasingly represented in the literature, further efforts are required to amplify their voices and address stigma. 

This review synthesized the current evidence and demonstrated how the work on FASD prevention has expanded in the recent years to reflect the nuance and interconnectedness of the Four-Part Prevention Model. The opportunities for prevention through research and evidenced-informed practice and policy are unlimited. We used the title “At a Juncture” as now we can definitely see a critical mass of research evidence on FASD prevention that can support practice and policy action related to awareness raising, brief support, wrap-around support, stigma reduction and change to alcohol policy!

FASD AWARENESS DAY 2022

It’s International FASD Awareness Day on September 9. We have now recognized this Day for over 20 years and it is heartening to see how many organizations and communities across Canada are now offering events and sharing resources that both honour the strengths of those with the disability and build awareness of the risks of drinking alcohol in pregnancy. One notable addition to this year’s events is that many landmarks and monuments across Canada will be lit up in red as part of CanFASD’s campaign, which focuses this year on building strengths and abilities.

As a part of our work to raise awareness about FASD prevention, we have updated an infographic about what we know about alcohol and pregnancy. It is based both in research and in the multi-level work of national, provincial, and local organizations working on FASD prevention. It points to:

• How women both deserve and benefit from information and support when making decisions about drinking before and during pregnancy.
• How reducing stigma about drinking is one key way of opening up the possibilities for women to access the information and support they need.
• How service providers have a prime responsibility in FASD prevention by:
  • Sharing informational materials, working collaboratively, and supporting connections to needed supports.
  • Engaging in non-judgemental and encouraging conversations about alcohol and associated risks.
  • Linking women to community-based programs that offer holistic support on alcohol use, other aspects of health, and practical needs.

The infographic offers links to excellent resources developed by Pauktuutit Inuit Women of Canada, the Saskatchewan Prevention Institute, organizations offering culture driven programming in 7 Indigenous communities, and the Co-Creating Evidence Project’s research on wraparound programming. The Centre of Excellence for Women’s Health is grateful to the CanFASD Research Network for providing the funding that affords us opportunity to bring attention to these FASD prevention efforts in Canada in this way. 

Prompting International Collaboration through an International Seminar Series on FASD Prevention

Research about preventing FASD is advancing across the globe and it is important that it be shared and acted upon. We see from our annual annotated bibliographies the amazing international work happening on the many levels of prevention – on awareness building approaches, on safe and respectful conversations about alcohol use with pregnant women, and on holistic support services for pregnant women and new mothers’ experiences of alcohol problems and other health and social concerns.

Leveraging off the work of researchers in Canada and internationally, the Canada FASD Research Network has sponsored a five-part seminar series bringing together 14 researchers from across the globe to share what is known about preventing alcohol use in pregnancy and supporting women’s health.

The five-part seminar series focuses on destigmatizing considerations, frameworks for FASD prevention, awareness raising and community development. Throughout the series, researchers from Canada, Australia, South Africa, USA, and New Zealand shared evidence on:

• The role and implications of stigma and FASD prevention efforts;
• Different frameworks for FASD prevention, including the four-part model of FASD prevention and holistic community-based prevention efforts;
• The development of FASD prevention guidelines;
• The ways to communicate information about alcohol use in pregnancy and FASD prevention;
• How to have collaborative conversations around alcohol and other substances during pregnancy – and the ways to translate perceptions of alcohol risks into successful interventions; and,
• Programs for pregnant and postpartum women and gender diverse individuals who use substances and their children.

This seminar series prompted collaboration in ways that historically have only been done at in-person conferences. Each seminar can be viewed in its entirety or as individual presentations. The goal is to provide service providers and leaders across the globe with user friendly access to FASD prevention research to inform their work when delivering and funding prevention efforts.

Through the international seminar series, we hope to make it possible for all countries to have access to what is known about preventing alcohol use in pregnancy.

We hope you will check out the seminar series available on the CanFASD YouTube page and prevention tab of the website.

FASD Prevention: An Annotated Bibliography of Articles Published in 2021

This year’s Annotated Bibliography of Articles Published in 2021 was just released and includes 99 articles from 21 countries.

Researchers associated with the Prevention Network Action Team (pNAT) of the Canada FASD Research Network search the academic literature for articles related to alcohol use in pregnancy and Fetal Alcohol Spectrum Disorder (FASD) prevention. Articles are reviewed for relevancy, identified by topic and country, and the findings are summarized.

Countries with the highest number of articles published were the US (36 articles), Canada (17 articles), and the UK (13 articles). The findings were organized using a four-part prevention model used by the pNAT to describe the wide range of work that comprises FASD prevention. This year, 35 articles described the prevalence, influences, and factors associated with alcohol use in pregnancy, nine articles described Level 1 prevention efforts, 26 articles described Level 2 prevention efforts, 7 articles described Level 3 prevention efforts, 8 articles described Level 4 prevention articles, and 17 articles described stigma, ethical issues, and systemic approaches.

In this collection of articles can be seen an increase in attention to women’s views and experiences. For example, a systematic review of qualitative research exploring the barriers and facilitators that influence alcohol reduction, abstention, and use in pregnancy found that social norms and relationships, stigma, trauma and other stressors, alcohol information and messaging and access to trusted and equitable care and resources greatly impacted women’s alcohol use and that structural and systemic factors related to alcohol use were widely underexplored. Another article explored how women make decisions about alcohol use given the conflict information, controversy, and stigma associated with light and moderate prenatal alcohol consumption. The authors found that women’s decisions were influenced by the consistency of messaging they received, their social position relative to the source of information, and the strength of the relationship to the person providing information.

The annual literature search is intended to update those involved in FASD prevention in Canada (and beyond), so that their practice and policy work may be informed by current evidence. The members of the pNAT also have the opportunity in monthly web meetings to discuss the implications of the findings for their work. You can access previous annotated bibliographies from CanFASD’s prevention page or by clicking on the “Maternal Health & Substance Use” topic on the CEWH publications page.

Click here to read FASD Prevention: An Annotated Bibliography of Articles Published in 2021.

Click here to read the Executive Summary.

The gift of sharing practice lessons

There are many influences, stressors and life circumstances that affect pregnant women’s and new mothers’ alcohol use, yet few so challenging and heartbreaking as the experience of intimate partner violence (IPV) and other forms of abuse.

Holistic community-based programs that aim to engage pregnant women and gender diverse individuals with lived experience of violence are challenged to help everyone feel safe, and to access the services that they and their children need. In many ways the overall service approaches of these programs – being harm reduction oriented, non-judgemental, culturally safe and trauma informed – go a long way towards creating the needed safety and support.

The Breaking the Cycle (BTC) program in Toronto took on the role of assisting community based programs that work with families who may be living with IPV, to articulate and enhance their support approaches. BTC received a grant from the Public Health Agency of Canada to develop and share with over 800 programs across Canada, both a resource manual (Building Connections: Supporting Community-Based Programs to Address Interpersonal Violence and Child Maltreatment) and training that helped these programs build further awareness of IPV and their capacity to deliver trauma informed approaches. Connections is a manualized group intervention that supports increased understanding by mothers about positive relationships and their importance to healthy parenting and healthy child development. This work illustrates BTC’s ever growing understanding of the many impacts of trauma on mothers and their children, and the importance of embedding trauma-informed approaches in the delivery of addiction, mothering and early childhood intervention services.

The Breaking the Cycle program recently published the findings arising from the evaluation of this work in the document “What we Learned”.  It documents the impact on: women who participated in the Connections groups, the group facilitators, other staff in the prenatal and child development organizations who engaged in the training and group delivery, and the organizations as a whole. Really compelling is the section on how women increased awareness of the impact of abuse, of children’s brain development, and of positive and mindful parenting; as well as their changes related to forgiveness and healing, self-care, self-esteem and empowerment. The facilitators also benefitted immensely in awareness, competency and overall through integrating and advocating for trauma-informed perspectives in their daily working relationships. The document is rich in detail about the impact of this important work to address intimate partner violence through relational and trauma informed approaches in community-based services, including Indigenous specific services.

Key to what they learned, Breaking the Cycle identified 4 fundamental practice principles which are definitely relevant to all the work we do on FASD prevention and intimate partner violence:

1. Readiness is critical. There is background work that must be done first, before a group like Connections that addresses trauma can be implemented.
2. Safety is vital. Trauma-informed principles must be established and integrated into your organizational practices before women will feel safe enough to get involved with Connections.
3. Relationships are the building blocks of engagement. Women who experience IPV have limited experience of supportive relationships and find building safe and healthy relationships with others, including their children, difficult. It is imperative that service providers model supportive relationships during the implementation of Connections.
4. Research and evaluation are critical components of all programs, with co-occurring commitment to respect community wisdom. The commitment to research and evaluation needs to be accompanied by a flexible group approach for participating organizations who know the needs of their communities best.

These lessons are a tremendous gift to all service providers who take on this important work. Much appreciated Breaking the Cycle!

Prevention of FASD through Preconception Conversations

In our work on FASD prevention, reaching women on the topic of the effects of alcohol use before they are pregnant is a much needed component. Yet when offering a continuum of perinatal and reproductive care, our health care systems usually do not make preconception health a priority. It is indeed a challenge to promote critical thinking about alcohol use in pregnancy when women a) are not yet actively planning a pregnancy,  b) are unaware, misinformed or unconcerned about of the effects of alcohol, or c) are acutely aware of the stigma associated with drinking alcohol in pregnancy and resistant to hearing the message.

In a recent article for the UK journal, International Journal of Birth and Parent Education, we described what is known about empowering and effective preconception health interventions, to catalyse and support the work of health care practitioners working with women of childbearing years.

We entitled the article “Beyond Screening” as it is important to enter discussions about alcohol use in pregnancy as conversations that reduce stigma and support critical thinking about alcohol use before, during, and after pregnancy.

In a section of the article entitled “Issues and Actions Needed” we offered 8 key considerations when offering preconception education and support on substance use issues:

1. moving beyond screening – Asking about what women know about effects of substance use in pregnancy and what their plans are, may be more engaging and helpful to open conversations, rather than starting with formal screening questions
2. reducing stigma – By naming how stigma and fears of judgement may be a barrier, health care providers can build an open relationship with women that facilitates safety and empowerment
3. involving women – In the context of substance use by women overall, and in pregnancy, where judgement, bias, discrimination, misinformation and stigma are rampant, it is particularly important to involve women respectfully and collaboratively in defining what works for them
4. involving men/partners– Involving partners in preconception and prenatal care, messaging, and support can be an important strategy for reducing the weight of pregnancy planning for women, and for improving overall health.
5. using technology – Web-based support on substance use issues is increasingly available to extend the reach and engagement by the public in early and accessible assistance. Sharing where such information is available, supports the seeking of assistance in an anonymous and self determining way
6. building on practitioner wisdom and relationships – Motivational Interviewing and other evidence informed practices are already being used by many practitioners for guiding conversations on substance use that are trauma informed, harm reduction oriented and strengths based. These approaches are highly relevant in conversations about substance use before, during and following pregnancy, and can be best ‘heard’ in conversations with trusted providers. 
7. multi-tasking – The benefits and reach of dual focus preconception interventions (that involve discussion of substance use with other health issues) are important. Integrating discussion of how alcohol may be a factor linked with nutrition, mental wellness, prevention of intimate partner violence and/or housing can be helpful, and respectful of women’s interests.
8. embedding preconception conversations in multiple systems of care – It is vital that preconception care be well integrated in health, social, and community care, with many types of practitioners all playing a role.

We are appreciative of being asked to revisit what we know about preconception interventions, and see it as important for everyone to ask of their communities and countries:

• Who is doing preconception interventions on alcohol and other substance use?
• In what additional contexts can preconception health and substance use issues be raised?
• How can we promote gender and other forms of equity as we are doing preconception interventions on substance use?
• What does each practitioner need to support action on this level of FASD prevention?