Our annual annotated list of research articles on FASD prevention is now available!

As in past years, we searched academic databases for articles about FASD prevention published in English over the past calendar year (in this case between January and December 2020). We organized the articles using the four-level prevention framework, so that those involved in FASD prevention can easily find and consider how to integrate current evidence relevant to their practice and policy work. 

This year, one hundred and three (n =103) articles were included, coming from 19 countries/regions.

  • 37 articles explored the prevalence of, and influences and factors associated with, alcohol use during pregnancy. Some factors influencing alcohol use in pregnancy described in these articles included depression, partners’ alcohol use, awareness of alcohol harms, awareness of pregnancy status, adverse childhood experiences, availability of support networks, concurrent tobacco smoking, and density of alcohol establishments.
  • 3 articles only focussed on awareness raising (Level 1).
  • 33 articles described aspects of brief intervention, education and support with women in childbearing years and their support networks (Level 2). Mixed results are still seen for brief interventions, but for some subgroups of women and dual interventions (alcohol + contraception) benefits were found.
  • 12 articles explored specialized, holistic support of pregnant women with alcohol and other health and social problems (Level 3), showing the importance of access to these programs and the need for collaboration in their delivery.
  • 7 articles described postpartum treatment and support approaches for new mothers and their children (Level 4), and promising approaches were described that included trauma informed and culturally grounded parenting programs.
  • 14 articles addressed overarching issues such as the impact of stigma, ethical issues and needed systemic approaches.

We encourage all those interested in FASD prevention to check out the articles for the area of FASD where they work, and in other areas of interest. We look forward to discussing key articles in the Prevention Network Action Team (pNAT) monthly web meetings as well. 

Preventing Fetal Alcohol Spectrum Disorder (FASD) requires a range of efforts from general awareness to targeted prevention and treatment services. In the Canadian Four-Part FASD Prevention Model, Level 3 and 4 programs provide low barrier holistic services for pregnant or parenting women who face substance use and a range of other health and social burdens and challenges.

Over a four-year period, the Co-Creating Evidence (CCE) evaluation study has involved eight different community-based Level 3 & 4 programs that support women through the provision of holistic, wraparound services, and in doing so, see FASD prevention as part of their mandate. These programs are guided by theoretical approaches such as being trauma-informed, relationship-based, women-centred, culturally grounded and harm reducing. The evaluation team has been led by the Nota Bene Consulting Group and has involved researchers from the Centre of Excellence for Women’s Health and representatives of the eight programs. 

This CCE evaluative study (2017-2020) has had three main research questions:

  1. What are the common elements of the diverse Level 3 programs across Canada?
  2. What program components are helpful from women’s perspectives?
  3. What are best measures to evidence outcomes and what outcomes are being achieved?

The answers to these questions are now available via:

In all these documents, service providers, researchers, policy makers and women with lived/living experience will see promising approaches and outcomes that these programs provide and the women who access these programs are realizing, together with their community partners. This study makes a significant contribution to our understanding of this level of FASD prevention. It hopefully will be an inspiration to all those committed to this important work. 

Funding for this project has been received from the Public Health Agency of Canada, Fetal Alcohol Spectrum Disorder (FASD) National Strategic Project Fund. The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada.

The Prevention Network Action Team (pNAT) recently had an inquiry from an ally about what research is available that informs us about the experience of mothers whose children have been diagnosed with a FASD (sometimes called “birth” mothers). While three researchers associated with the pNAT have undertaken research with mothers for their Master’s or PhD theses (Dr. Amy Salmon, Dr. Dorothy Badry and Dr. Kelly Coons-Harding) we realize that this is a significant gap in the available published research!

We have relied (and will continue to rely!) on the wisdom of mothers who have presented with us at FASD conferences, people such as Pip Williams (UK), Elizabeth Russell (AU), Lisa Lawley and Janet Christie (CA) and Kathy Mitchell (US). Their courageous and thoughtful work as addiction coaches, spokespersons and organizers of networks has contributed so much to our understanding of the issues they have faced, and to the benefits of peer support for mothers who deserve such wise and kind mentors. 

In addition to the wisdom of mothers, to answer the request for information, we gathered – see the list below – the academic literature specifically about biological mothers of children with FASD, and welcome readers to send us further links. Here are a few key ideas that emerge from these articles.

  • Stigmatizing attitudes prevail – Mothers who have been interviewed by researchers describe societal and service provider ignorance about FASD, and harsh judgements directed to women who drink in pregnancy.  This perpetuates the reluctance of women to access support. When mothers do access care for themselves and their children, they report additional unintended stigma from physicians and diagnostic teams.
  • Addiction and other overwhelming influences – Most often in the studies, mothers describe having a family history of alcohol problems and/or mental illness, addiction problems themselves and histories of intimate partner violence. And they note that services which are welcoming, non-judgemental and integrate support on trauma/violence, substance use/addiction and women’s/maternal health are not usually readily available.
  • Transformation – Some women described that having a child with FASD gave them a reason to stay sober and in effect saved them from a life of addiction and possible death. In essence, it caused a major shift to a recovery trajectory for them.  A part of the transformation is empowerment related to knowing they are helping to break the generational cycle of trauma and addiction in their family. The courage and ongoing effort involved, and the external challenges encountered related to recovery, stigma and parenting a child with FASD are formidable.
  • Adapting to motherhood and becoming advocates – The journey of becoming a mother, addressing an addiction problem, and raising a child with a disability is a very special path. Often mothers noted that they shifted gears to be the best advocate they can be for their child, and to become advocates on the issue to help other women by increasing awareness of FASD, and of how mothers can and do make adaptations and become advocates.

Studies about the perspectives of mothers who have given birth to a child with FASD

Badry, D.E. (2008), “Becoming a birth mother of a child with fetal alcohol syndrome”. Dissertation

Stewart, M., Lawley, L., Tambout, R., & Johnson, A. (2018). Listening in a Settler State: (Birth) Mothers as Paraprofessionals in a Response to FASD. In D. Badry, H. Montgomery, D. Kikulwe, M. Bennett, & D. Fuchs (Eds.), Imagining Child Welfare in the Spirit of Reconciliation: Voices from the Prairies (pp. 117-138): University of Regina Press.

Salmon, J. (2008). FASD: New Zealand Birth Mothers’ Experiences. Canadian Journal of Clinical Pharmacology, 15(2), e191-213. 

Thomas, R., & Mukherjee, R. (2019). Exploring the experiences of birth mothers whose children have been diagnosed with fetal alcohol spectrum disorders: a qualitative study. Advances in Dual Diagnosis, 12(1/2), 27-35. doi:10.1108/ADD-10-2018-0014

Studies about mothers of children with FASD (birth, foster, adoptive), societal attitudes and research engagement

Salmon, A. (2007). Walking the talk: how participatory interview methods can democratize research. Qual Health Res, 17(7), 982-993. doi:10.1177/1049732307305250

Coons, K. D., Watson, S. L., Schinke, R. J., & Yantzi, N. M. (2016). Adaptation in families raising children with fetal alcohol spectrum disorder. Part I: What has helped. Journal of Intellectual & Developmental Disability, 41(2), 150-165. doi:10.3109/13668250.2016.1156659

Corrigan, P. W., Lara, J. L., Shah, B. B., Mitchell, K. T., Simmes, D., & Jones, K. L. (2017). The Public Stigma of Birth Mothers of Children with Fetal Alcohol Spectrum Disorders. Alcohol Clin Exp Res, 41(6), 1166-1173. doi:10.1111/acer.13381

Shahram, S. Z., Bottorff, J. L., Kurtz, D. L., Oelke, N. D., Thomas, V., & Spittal, P. M. (2017). Understanding the Life Histories of Pregnant-Involved Young Aboriginal Women with Substance Use Experiences in Three Canadian Cities. Qual Health Res, 27(2), 249-259. doi:10.1177/1049732316657812

Harm reduction and health promotion for women and their partners before conception are key to FASD prevention [1]. Providing health information and supports during the preconception period provides an opportunity for men and women to actively plan for a healthy pregnancy and learn strategies such as healthy nutrition, supplementation, and reducing alcohol and other substance use [2]. Such education and support can contribute greatly to optimizing health and preventing FASD [3].

Around the world, there are examples of unique approaches to preventing alcohol exposed pregnancies. Some interventions are geared towards women and men separately, and others are gender synchronized, creating complimentary programs for men, women, boys, and girls. Interventions may also include both members of a couple and include training for healthcare professionals.

Credit: Pretestie Bestie campaign.

Websites, such as Healthy Families BC and the Society of Obstetricians and Gynaecologists of Canada have pages offer information about alcohol use during pregnancy and clear and concise steps to consider before becoming pregnant. The recent ThinkFASD website sponsored by the CanFASD Research Network offers advice both for couples who are consciously planning a pregnancy, and those who are drinking and having unprotected sex. Other websites are interactive, such as Alberta Health Services’ Ready or Not, which allows a woman to click through different resources and prompts based on whether or not she feels ready to become pregnant. Don’t Know? Don’t Drink is a creative campaign in New Zealand, which posts fun, engaging graphics and videos to their social media platforms with messages about using contraception and supporting friends to not drink if there’s a chance they might be pregnant. The campaign caters to younger girls and encourages finding a “Pretestie Bestie”, a friend who supports you and your decision making before getting a pregnancy test, as a strategy of FASD prevention.

Interventions in the preconception period are not limited to women. Paternal drinking can impact men’s safety, sperm health, fetal/infant health, and women’s ability to reduce their alcohol use [4]. Various programs have been geared towards men’s education about contraception options, reproductive health, and how to support partners in their efforts to reduce drinking before and during pregnancy. Project Alpha is an American collaboration aimed at educating boys age 12 to 15 about fatherhood, contraception, healthy relationships, and sexuality.

MenCare+ empowers men to be active and positive participants in their own health as well as the health of their partners and children.  It has been implemented in Brazil, Indonesia, Rwanda, and South Africa and has been shown to reduce intimate partner violence in its participants, which is an important contributing factor to women’s substance use during pregnancy [5]. In addition to programming for men, MenCare also offers workshops and training for healthcare professionals on engaging men in maternal and child health.

The internet has been a preferred source of information when it comes to preconception [6] and for couples who know they want to have children, web-based interventions are helpful tools. The UK’s Smarter Pregnancy program helps couples build a profile through an online health assessment and then offers evidence-based recommendations based on their profile. A similar approach is taken by HealthyMoms and HealthyDads complimentary websites, which were created after asking expectant moms and dads what  information and supports they need to prepare for parenthood.

Culturally safe and non-judgemental interventions have been shown to be effective in reducing the risk of alcohol exposed pregnancies [7]. In the US, CHOICES and Amor Y Salud are interventions geared towards Indigenous and Latinx communities. CHOICES educates non-pregnant at-risk women about contraceptive options and uses motivational interviewing to support women to reduce drinking. Amor Y Salud, available through the Oregon Health Authority Website, offers a radionovela that follows a young couple as they learn how to optimize their health and prepare for future children. In Canada, Best Start’s website has a page for Indigenous prenatal health with information and resources that integrates Indigenous knowledge with Western health information. They also provide resources, such as Planning for Change, to support healthcare providers in educating their patients about FASD and supporting them in making meaningful changes.

The variety of preconception education and support approaches illustrates opportunities for incorporating these initiatives across the various levels of reproductive health. Childbearing years span four decades for women and are longer for men, and interventions have and can continue to focus on those that are planning or not yet planning a pregnancy, as well as for those in the period before a pregnancy is confirmed. When such preconception and early pregnancy supports are well incorporated throughout the healthcare system, this key component of FASD prevention can be realized.

1. Network Action Team on FASD Prevention. (2010). Consensus on 10 fundamental components of FASD prevention from a women’s health determinants perspective. Canada Northwest FASD Research Network.

2. The Centre of Excellence for Women’s Health. (2016). Preconception Interventions Alcohol and Contraception Example. Schmidt, R., Hemsing, N., & Poole, N. Retrieved from http://en.beststart.org/sites/en.beststart.org/files/u4/PC3-Preconception-Interventions-Poole.pdf

3. Webb, Shelby, and Diane Foley. “An Introduction to the Optimal Health Model for Family Planning Clinicians.” National Clinical Training Center for Family Planning, 17 Feb. 2020, http://www.ctcfp.org/optimal-health-podcast/.

4. McBride, N. and S. Johnson, Fathers’ role in alcohol-exposed pregnancies: Systematic review of human studies. American Journal of Preventive Medicine, 2016

5. Alhusen JL, Ray E, Sharps P, Bullock L. Intimate partner violence during pregnancy: maternal and neonatal outcomes. J Womens Health (Larchmt). 2015 Jan;24(1):100-6. doi: 10.1089/jwh.2014.4872. Epub 2014 Sep 29. PMID: 25265285; PMCID: PMC4361157.

6. Da Costa D, Zelkowitz P, Bailey K, Cruz R, Bernard JC, Dasgupta K, Lowensteyn I, Khalifé S. Results of a Needs Assessment to Guide the Development of a Website to Enhance Emotional Wellness and Healthy Behaviors During Pregnancy. J Perinat Educ. 2015;24(4):213-24. doi: 10.1891/1058-1243.24.4.213. PMID: 26834443; PMCID: PMC4718007.

7. Hanson, J., & Pourier, S. (2015). The Oglala Sioux Tribe CHOICES Program: Modifying an Existing Alcohol-Exposed Pregnancy Intervention for Use in an American Indian Community. International Journal of Environmental Research and Public Health, 13(1), 1. doi:10.3390/ijerph13010001


Adopting a relational approach to FASD prevention has been identified as one of the 10 fundamental components of FASD prevention from a women’s health determinants perspective1. This approach recognizes that relationships are central to our lives and therefore processes of healing and change cannot occur without addressing disconnection and isolation.

Building trusting and supportive relationships is foundational to women feeling safe and confident enough to take on the challenges of reducing substance use, addressing trauma, and parenting. As such, the relational approach addresses a core aspect of women’s health, stimulating a ripple effect that can enact change and growth in the lives of women at risk of having children with FASD.

Breaking the Cycle (BTC) has been delivering services using a relational lens since 1997 and have found that relationships facilitate healing and change for mothers, children, and the mother-child dyad through improving self-efficacy, instilling purpose, and increasing engagement in services2. The program emphasizes relationships of many types, including those among staff, between women and their children, staff and women, and the organization and service partners.

Breaking the Cycle Compendium Volume 2 – Healing Through Relationships  compiles research conducted between 2008 and 2018, and the evidence shows that the relational approach offers opportunities to model relationships based on equality, empowerment, and respect, and that having strong relationships with service providers can have more impact on women’s health than the services themselves. Additionally, emphasizing interagency and intra-agency relationships and collaborations better positions a program to meet the needs of the women and children receiving services3. Through this approach, the BTC program has been successful in preventing FASD and has also positively increased confidence in parenting and mother-child bonds.

In focusing interventions and preventative efforts on building belonging and connection, existing and future programs can better address root causes of women’s substance use. It is from here that we can stimulate a ripple effect to make positive changes in the psychological, emotional, and physical health of mothers and their children.

1. Network Action Team on FASD Prevention. (2010). Consensus on 10 fundamental components of FASD prevention from a women’s health determinants perspective. Canada Northwest FASD Research Network.

2. Motz, M., Reynolds, W., Leslie, M. (2020). The Breaking the Cycle Compendium Volume 2 – Healing Through Relationships. Toronto: Mothercraft Press.

3. Network Action Team on FASD Prevention. (2010). Taking a relational approach: The importance of timely and supportive connections for women. Canada Northwest FASD Research Network.

Twenty years ago, Astley, Bailey, Talbot, and Clarren (2000) [1] published a study that revealed how common intimate partner violence (IPV) was amongst mothers of children with FASD. The study showed the importance of thinking broadly about the risk factors and influences of FASD and demonstrated that preventing violence against women is also a preventative measure for FASD. Research efforts since Astley et al.’s study in 2000 have continued to show that IPV is an important factor to consider when supporting pregnant women who use alcohol and other substances [2].

This year, researchers at the Centre of Excellence for Women’s Health (CEWH) have been conducting a rapid review to understand the complex, multi-directional relationship between IPV and substance use during the COVID-19 pandemic and provide available and accessible research evidence to frontline providers [3]. Since the implementation of stay at home orders and social distancing recommendations, use of substances and experiences of IPV have increased. Canadians have reported an 18% increase in alcohol consumption[5] due to the stress, boredom, and lack of a regular schedule brought on by the COVID-19 pandemic[6]. One in 10 Canadian women are concerned for their safety[4] and calls to the Battered Women’s Support Services in Vancouver have tripled, demonstrating an increase in help seeking by women. These findings highlight the importance of understanding how public health policies and recommendations that help curb the spread of COVID-19 can be used by partners who cause harm in coercive and controlling ways.

In our efforts to prevent and reduce substance use during pregnancy, collaboration among service providers in substance use and IPV services is essential. Understanding the interconnectedness of these issues and how they are affected by pandemics and disasters can help us address them collectively. As examples, the Learning Network at the Centre for Research & Education on Violence Against Women & Children [7] and Calgary Women’s Emergency Shelter [8] have developed educational materials to help us understand how to support women who are experiencing IPV during the ongoing pandemic. As we deepen our understanding of the risk factors for FASD to include psychosocial factors such as IPV, materials like these can help us incorporate holistic support into service provisions and better support women who are experiencing violence and aggression during the COVID-19 pandemic.

Excerpt from the Learning Network at the Centre for Research & Education on Violence Against Women & Children’s 3 Considerations for Supporting Women Experiencing
Intimate Partner Violence During the
COVID-19 Pandemic
guide

  1. Astley, S. J., Bailey, D., Talbot, C., & Clarren, S. K. (2000). Fetal alcohol syndrome (FAS) primary prevention through fas diagnosis: II. A comprehensive profile of 80 birth mothers of children with FAS. Alcohol and alcoholism (Oxford, Oxfordshire)35(5), 509–519. https://doi.org/10.1093/alcalc/35.5.509
  2. https://bccewh.bc.ca/?s=FASD+revention%3A+An+Annotated+Bibliography+of+Articles
  3. https://bccewh.bc.ca/featured-projects/covid-19-substance-use-and-intimate-partner-violence/
  4. Statistics Canada, Canadian Perspectives Survey Series 1: Impacts of COVID-19. 2020, Ottawa, ON: Statistics Canada.
  5. NANOS Research, COVID-19 and Increased Alcohol Consumption: NANOS Poll Summary Report. 2020.
  6. Statistics Canada. Canadian Perspectives Survey Series 1: Impacts of COVID-19. 2020; Available from: https://www150.statcan.gc.ca/n1/daily-quotidien/200408/dq200408c-eng.htm
  7. http://vawlearningnetwork.ca/our-work/infographics/covid19safety/LN-Safety-COVID-19-PDF-1.pdf
  8. https://www.calgarywomensshelter.com/images/CWES_COVIDsupport_Final_April_2020.pdf

Examples of Holistic FASD Prevention in Practice

Developing specialized, culturally safe, and holistic support for pregnant women is an important strategy in preventing FASD [1]. In Labrador, Thea Penashue and June Fry of the Innu Roundtable Secretariat are bringing Innu midwifery and parenting back to Sheshatshiu and Mushuau Innu First Nations through two initiatives.

Centering Pregnancy was introduced in Sheshatshiu in 2018 to increase access to and use of primary prenatal care. The project was born from dialogues between the Innu Round Table Secretariat, Innu Health Directors, the Regional Health Board, physicians, and public health nurses. Centering Pregnancy is a group pregnancy outreach program where women can access prenatal group education, health assessments, and social support. The program promotes relationship-building by allowing participants to bring supports with them to the group sessions and encouraging discussion and bonding between women within the program. Expectant mothers have autonomy and control in their care in addition to support from a health care worker [2].

The Innu Midwifery Project aims to reintroduce traditional midwifery to Sheshatshiu and Natuashish, drawing on Innu Elders’ knowledge of Innu birthing practices. The project is being done in collaboration with Gisela Becker, the Chief Midwife for Newfoundland and Labrador, to support the training Innu midwives using a culturally-specific, hands-on, individually paced learning approach. Reintroducing midwifery to the Innu First Nations will result in Innu children being born on Innu lands, fostering a greater connection to the land and culture, continuation of cultural practices and culturally safe care, and empowering women in the context of their pregnancy.

Credit: “A Guide to the Innu Care Approach” from the Innu Round Table Secretariat website [5].

These initiatives create a safer environment for Innu women to discuss their health. Based in and driven by the communities and culture, these programs are centered around women, their families, and the communities [3].

Thea Penashue, the Community Wellness Systems Navigator at the Innu Round Table Secretariat, delivered her second child in a tshuap, a traditional Innu tent, in September. She hopes that, through the Midwifery project and Centering Pregnancy program, more Innu women will be able to give birth in a tshuap, connecting to their land, culture, and sense of self as Innu people, in the company of their loved ones [4].

Credit “A Guide to the Innu Care Approach” from the Innu Round Table Secretariat website [5].

1. Canada FASD Research Network’s Action Team on FASD Prevention from a Women’s Health Determinants Perspective, 2013. PREVENTION Of Fetal Alcohol Spectrum Disorder (FASD) A Multi-Level Model. [online] Available at: <https://canfasd.ca/wp-content/uploads/2016/09/PREVENTION-of-Fetal-Alcohol-Spectrum-Disorder-FASD-A-multi-level-model.pdf&gt; [Accessed 24 September 2020].

2. Centering Healthcare Institute. n.d. Centering Pregnancy | Centering Healthcare Institute. [online] Available at: <https://www.centeringhealthcare.org/what-we-do/centering-pregnancy&gt; [Accessed 24 September 2020].

3. Network Action Team on FASD prevention, 2010. Consensus Statement On 10 Fundamental Components Of FASD Prevention From A Women’S Health Determinants Perspective. [online] Canada Northwest FASD Research Network. Available at: <https://canfasd.ca/wp-content/uploads/2016/09/ConsensusStatement.pdf&gt; [Accessed 24 September 2020].

4. CBC, 2020. This Mom Is Bringing Back An Innu Tradition, By Giving Birth In A Tent To Connect With Her Roots. [online] Available at: <https://www.cbc.ca/news/canada/newfoundland-labrador/penashue-tent-birth-1.5713780&gt; [Accessed 24 September 2020].

5. Innu Round Table Secretariat, 2017. A Guide To The Innu Care Approach. [online] Available at: <http://www.irtsec.ca/2016/wp-content/uploads/2018/01/A-Guide-to-the-Innu-Care-Approach-Dec-2017.pdf&gt; [Accessed 24 September 2020].

FASD Awareness Day started on September 9, 1999 to bring global awareness to Fetal Alcohol Spectrum Disorder (FASD).

FASD Month Campaign-07This year, Canada FASD Research Network (CanFASD) is launching FASD Awareness Month for all of September. The goal is to bring awareness to what FASD is and challenge the stigma and misinformation surrounding the disability. In preparation, they have released a toolkit with information about FASD, speech-writing tips, and images that are strengths-based, non-judgemental, and person-centered as to reduce the stigma around FASD, alcohol, and pregnancy.

CanFASD’s campaign explores how FASD is many things; including a women’s health issue. Preventing FASD requires supporting women in addressing the issues that contribute to their substance use and experience of trauma. When women receive non-judgemental support that is tangible and offers practical help, women are able to reduce or abstain from substance use, improve their health, and be empowered mothers.

Positioning FASD as a woman’s health issue recognizes:

FASD Month Campaign-05

  • Communities’ roles in healthy pregnancies;
  • Service providers’ role in delivering services that women need (i.e. housing, employment, nutrition, anti-violence, substance use) in an accessible and non-judgemental way;
  • Governmental roles in creating evidence based alcohol policy, and addictions & child welfare policies that prioritize wrapping support around the mother-child unit; and,
  • Society’s role in learning more about alcohol use in pregnancy and FASD.

Women are increasingly accessing pregnancy applications (‘apps’) as a primary source of information about health changes in pregnancy and fetal development. Pregnancy apps have features that track pregnancy signs and symptoms, do gestation calculations, and can blend functions to integrate games, social networking options, etc. [1]. Apps are well situated for women to safely and confidentially seek information that they may not feel comfortable asking of their health care professional.

Although most women use pregnancy apps for information seeking, many apps lack trusted information on important topics such as alcohol use, in part due to the limited involvement of informed health professionals and women knowledgeable about harm reduction in the content development process [1].

fasd blog June 2020

The ability to access evidence-based resources on alcohol use during pregnancy and FASD that is non-judgmental, trauma-informed, and harm reduction oriented, is more important than ever. Integrating Messages about Alcohol Use in Pregnancy and FASD: Guidelines for Pregnancy App Developers was created due to the increasing demand for pregnancy apps, paired with the need for consistent, evidence-based information across platforms.

These recommendations provide app developers with insight on how to frame messages about alcohol use and pregnancy so they are strengths-based, trauma-informed, and harm reduction oriented; recognizing that pregnancy apps are well positioned to offer women advice, links to local and national resources, and strategies that address women’s substance use and the influences on women’s drinking.

The recommendations address how there are many reasons why women may drink alcohol or use other substances during pregnancy; that reasons for alcohol use may change over the course of their pregnancy; and that a great deal of conflicting information about alcohol use and pregnancy exists. It is helpful to women and to service providers when health messaging about reducing stress, finding healthy coping strategies, enhancing support through safe relationships, and navigating social situations is integrated with information about the risks of alcohol/other substance use in pregnancy. We invite and encourage all those writing blogs and designing apps about health issues in pregnancy to use the guidance provided so that empowering and helpful information about reducing/stopping alcohol use when pregnant is consistent, becomes readily available, and discussed on all platforms.

 

  1. Hughson, J.P., Daly, J. O., Woodward-Kron, R., Hajek, J. Story, D., The rise of pregnancy apps and the implications for culturally and linguistically diverse women: Narrative review. Jmir Mhealth and Uhealth, 2018. 6(11): p. e189.

Beautiful black mother breastfeeds her newborn sonTwo updated resources are available about alcohol and breastfeeding: a research update from CanFASD Alcohol and Breastfeeding and a brochure from Best Start  Mixing Alcohol and Breastfeeding.  They both illustrate how little research there is available, and how public health messaging directed to new mothers has changed over time.

The public health message currently offered to mothers is that it is safest not to drink alcohol when breastfeeding and if one chooses to drink, to avoid drinking near the time of breastfeeding, so that infants are exposed to the very least amount of alcohol. Some recent studies about alcohol use when breastfeeding have not found negative effects for infants – and instead, have found that low level drinking during breastfeeding was not associated with shorter breastfeeding duration or adverse outcomes in infants up to 12 months of age. These adverse outcomes included effects on infant feeding and sleeping behaviour, as well as developmental outcomes [1].

Yet, infants cannot metabolize alcohol in the same way as adults, and exposure to alcohol places them at risk of potential alcohol-related harm, in the short, if not long term.  As a result, the weight of decision-making about breastfeeding and drinking alcohol rests on women. What is low level drinking, and how can one assess the many confounding factors related to alcohol’s effects – sex, genetics, nutrition, use of other substances, etc.? All of these issues are in play for their own, and their infant’s health.

Similarly, in light of cannabis legalization, more attention has been placed on the impact of cannabis use on breastfeeding. As with alcohol, initial public health messaging focussed on the studies that showed risk.  But, a recent review of the literature led by Dr. Alice Ordean of St Joseph’s Health Centre in Toronto, found only two articles that addressed the impact of postpartum cannabis use by lactating women that provided developmental outcomes for infants [2]. That review found some evidence regarding health risks of post-natal exposure to cannabis, but the authors noted that further research is needed to determine the impact of cannabis exposure via breastmilk on infant neurodevelopmental outcomes beyond the first year of life. They concluded that given the conflicting evidence on outcomes from exposure to cannabis in breast milk, women are advised that it is safest to abstain from cannabis use during lactation and to reduce consumption and plan timing for least exposure, if abstinence is not possible.

What has changed in our public health messaging? As well as repeating the sound advice that it is safest not to use these substances when breastfeeding, practical harm reduction advice is also offered.  In the case of alcohol, women are advised to plan ahead to consume alcohol immediately after, and not before, breastfeeding, so that infants are exposed to the very least amount of alcohol.  In the case of cannabis, women are advised to avoid breastfeeding within 1 hour of inhaled use to reduce exposure to highest concentration of cannabis in breast milk.

In addition to what is known and not known about the effects of exposure to substances when breastfeeding, there are many other reasons women may need to think critically about their alcohol and cannabis use as new mothers. These include relational attachment, fatigue, risk of exposure to 2nd and 3rd hand smoke for infants and children, and role modelling healthy behaviour.  With limited evidence, the benefits and drawbacks of low level alcohol and/or cannabis use will continue to be forefront for breastfeeding mothers.

  1. Tay, R.Y., et al., Alcohol consumption by breastfeeding mothers: Frequency, correlates, and infant outcomes. Drug and Alcohol Review, 2017. 36: p. 667-676.
  2. Ordean, A. and G. Kim, Cannabis Use During Lactation: Literature Review and Clinical Recommendations. Journal of Obstetrics and Gynaecology Canada, epub January 25, 2020.

See
Alcohol and Breastfeeding. CanFASD Research Network April 2020
https://canfasd.ca/issue-papers-alerts/#1566440340786-344b257b-3fa1
Mixing Alcohol and Breastfeeding. Best Start/Health Nexus 2020
https://resources.beststart.org/product/a21e-mixing-alcohol-and-breastfeeding-brochure/
Cannabis Use During Pregnancy & Lacatation: Practice Resources for Health Care Proivders. Perinatal Services BC 2020
http://www.perinatalservicesbc.ca/Documents/Resources/HealthPromotion/cannabis-in-pregnancy-pratice-resource.pdf

Overview: Four Levels of FASD Prevention

Information Sheet: What Men Can Do To Prevent FASD

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