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?

How interagency and cross-sectoral partnerships are contributing to prevention of FASD

Over the past three years, the Co-Creating Evidence study (CCE) has been exploring best practices in the delivery of community-based wraparound programs that support pregnant and parenting women with substance use concerns in Canada. The CCE team recently published an article about how the partnerships fostered and maintained by community-based wraparound programs make a difference in their work and are in fact a best practice.

The CCE project team interviewed 60 partners and 108 staff of the eight programs involved in the CCE study. The interviews focused on the nature and benefits of interagency and cross-sectoral partnerships. The study found that these programs most commonly formed partnerships with child welfare and health services such as primary care, public health, mental health services and maternal addictions programmes, yet they also partnered to some degree with housing, income assistance, Indigenous cultural programming, infant development and legal services.

Key benefits of partnerships identified were:

  • improved access by clients to health and social care that addresses social determinants of health. This access includes expanded programming in the program sites, increased understanding of partners’ services, and greater ease of referral to other supports and programs as needed by clients.
  • increased knowledge on the part of both the interagency partners and the wraparound service providers about the experiences that women face, such as the significance of poverty and trauma to women’s substance use. In turn this positively promotes non-judgemental and trauma-informed approaches with pregnant women and new mothers, as well as provision of more multifaceted and paced supports to address their needs.
  • improved child welfare outcomes. The program level relationships with child welfare workers, and in some cases integration of a social worker onsite, results in increased planning for positive mother-child outcomes during the pregnancy, improved mother-child connections after birth and reduced likelihood of the infant being removed from the woman’s care at birth.
  • strengthened cultural safety within the programming and (re)connection to culture by women. Partnerships with Indigenous organizations enhances learning by program providers about how to work in a culturally safe way and increased opportunities for referral to Indigenous programming for those women interested in connecting to their culture as a part of their wellness/recovery.

“The programmes participating in the Co-Creating Evidence study were both creative and flexible when developing partnerships, seeking opportunities in areas in which they did not have the resources or expertise, as well as with services with whom they had a common cause, for example mutual clients, a shared desire to ‘wrap support’ around women to meet their evolving needs and aligned approaches (harm reduction, trauma informed practice).”

Hubberstey, C., Rutman, D., Van Bibber, M., & Poole, N. (2021). Wraparound programmes for pregnant and parenting women with substance use concerns in Canada: Partnerships are essential Health and Social Care in the Community  https://onlinelibrary.wiley.com/doi/epdf/10.1111/hsc.13664

The partnerships continue to evolve through dialogue, collaboration and communication. What the study has identified is how, through these partnerships, wraparound program providers are contributing to the reduction of fragmentation between the health, child welfare and addictions fields – and in turn to important benefits for clients in terms of access to care and enduring connections with their children. In the work on prevention of FASD, it has repeatedly been emphasized how important the role of “Level 3 and 4” programming is, particularly in how such programs attend to the range of determinants of women’s health and alcohol use. Clearly it is in part through partnership work that FASD prevention is achieved.

Addressing stigma as a catalyst to reduce alcohol use in pregnancy

Substance use and addiction are highly stigmatized, particularly for pregnant women and women of reproductive age. Women who use substances often experience multiple forms of stigma and are required to navigate notions of ‘good’ motherhood. This can contribute to women’s own belief that substance use during pregnancy is an uncaring choice. Despite the pervasiveness of stigma and public health efforts to counter it and to help women prevent Fetal Alcohol Spectrum Disorder (FASD), women’s alcohol use during pregnancy is expected to increase.

Researchers from the Centre of Excellence for Women’s Health, University of Queensland, and the Canada FASD Research Network published a study exploring women’s reasons for continued alcohol use, reduction, and abstinence during pregnancy (1). In their research, they found that there is very little research that highlight’s women’s voices in efforts to understand the barriers and facilitator’s to alcohol use in pregnancy.

To analyze women’s reported barriers and facilitator’s to reducing alcohol use in pregnancy, the authors used the Action Framework for Building an Inclusive Health System. It was released in 2019 with Canada’s Chief Public Health Officer of Health’s 2019 report, and outlines different levels of stigma (individual, interpersonal, institutional, and population) and how they operate.

Stigma remains a pervasive challenge for pregnant and parenting women who use alcohol and other substances when accessing and receiving care. Interestingly, despite the literature’s focus on women’s individual choice about prenatal alcohol use, the barriers and facilitators to women’s alcohol use in pregnancy identified in this study were a result of interpersonal, institutional, and population-level factors, not individual choice.  

In Canada, toolkits and policy papers have been developed to contribute to addressing stigma and related barriers. In many countries, interventions are being developed and evidenced by communities and by health and other systems of care that are designed to reduce stigma and support women’s engagement in care, including:  

  • inclusive awareness building that reaches women, their partners and the public
  • relational, trauma-, gender- and culture-informed support offered by health and social care providers; and,
  • welcoming, non-judgmental services that wrap a wide range of needed practical supports around mothers and their children.

These interventions act as remedies to the challenges cited by pregnant women who use alcohol and find it difficult to reduce/stop alcohol use in pregnancy. In this way, action to prevent FASD can move beyond the usual recommendations for supporting individual change to be more accurately focused on service and system level changes that have the potential to make individual change possible.


  1. Lyall V, Wolfson L, Reid N, Poole N, Moritz KM, Egert S, et al. “The Problem Is that We Hear a Bit of Everything…”: A Qualitative Systematic Review of Factors Associated with Alcohol Use, Reduction, and Abstinence in Pregnancy. Int J Environ Res Public Health. 2021;18(7).

Where there’s a will, there’s a way. US system-level action to institute Plans of Safe Care

Members of the Prevention Network Action Team recently attended a webinar sponsored by the Children and Family Futures Program (CCFutures) in the US. During the webinar, a CFFutures representative shared how Plans of Safe Care (POSCs) were being developed to support women who are using substances during pregnancy and promote mother/child togetherness at the time of delivery.

These POSCs are being instigated by court teams, who convene multi-agency collaborations that include child welfare, substance use treatment and OAT providers, medical/health care providers and children’s services, including home visitation and peer recovery supports.  The peer supports play a key role in engaging families in voluntary services prenatally or prior to child welfare involvement, helping them navigate social services systems, as well as assisting with creating and monitoring the POSC, and providing important insights into barriers experienced by the families.

This POSC approach has the benefits of forging strong and deliberate partnerships across providers and is positively informing child welfare responses to women and infants where there has been prenatal substance exposure. This work to provide organized, trauma-informed and effective care prenatally is preventing removal of children at birth and family separation overall. At the court level, it is integrating a prevention mindset by asking what it would take to maintain the child in the home and ensure that reasonable and active efforts are made to support the woman’s and family’s health. At the community level, it involves the funding of community coordinators to oversee collaboration and implementation, as well as community education and training. It means that there is coordination from pre-to postnatal care, and that continuity of services is provided. And it is reducing NICU stays and the need for pharmacological interventions.

This is an excellent example of system level change to prevent FASD, as opposed to individualizing and medicalizing the response. The leaders cite similar barriers to what has been identified in many locations and in research about system-level barriers including limited staff and system capacity, concerns about confidentiality, stigma, as well as lack of knowledge about POSCs and their benefits – yet they are addressing these.  One of the sites was quoted to say that most of the efforts did not require funding, with the implication that the accomplishments can be sustained in the local systems of care.  Instead of requiring significant additional funding for the POSC work they “required commitment and investment by all involved parties to systems change and improved practices – collaboratively and individually – as providers and entities working with the target population.”

The description of this fine work has echoes in the conversations we at the Prevention Network Action Team have had over the years, and when developing the Mothering and Opioids: Addressing Stigma-Acting Collaboratively resource (see the policy values diagram from that resource below).  Many of us have, and continue to, advocate for and deliver components of this coordinated system level response. The webinar covered the solid evaluation evidence for this type of response in detail, but the big story is that system level can be done that effectively and safely supports women, children and families.  Where there’s a will, there’s a way.

Source: Page 42, Mothering and Opioids Toolkit

September – A Month Dedicated to Raising Awareness of FASD and its Prevention

In September each year, efforts are made to raise public awareness of FASD as a disability and of FASD prevention.  Here we describe some of the great work that is being done.

Awareness of FASD as a disability – It is important to build awareness of the disability and how to support people living with FASD. This year, a report entitled Excluded: Increasing Understanding, Support and Inclusion for Children with FASD and their Families was developed by the Office of the BC Representative for Youth, with the involvement of people living with FASD. It provides a clear description of the effects of FASD and its challenges for individuals. It also looks at the challenges and gaps in support in educational, health, justice and other systems, and makes recommendations for addressing these gaps and challenges. Another resource of note about provision of support over the lifespan is Towards Healthy Outcomes for Individuals with FASD by the CanFASD Research Network in collaboration with the University of Alberta.

Awareness about alcohol use in pregnancy via educational materials and messaging – Every province and territory in Canada is working to some degree on FASD prevention awareness through informational materials, posters or social media posts. The Saskatchewan Prevention Institute (SPI) does a remarkable job of advocating for “changing the conversation” via an informational website and posters with modern images and encouraging messages. Click here for more information. SPI is consciously working to prevent stigma and uses this approach with the language and images in their prevention messaging, which are described in guidelines created by the CanFASD Research Network. Also within this year, the BC government updated and expanded their public Health File about FASD prevention. Click here for more information.

Alcohol policy initiatives – Warning labels have been found to play a small but important part in raising awareness about not drinking in pregnancy. In the past year The Foundation for Alcohol Research and Education (FARE) in Australia led a successful campaign for mandatory, visible pregnancy health warnings on all alcohol products in Australia and New Zealand. It is worth reading about how they achieved this, through broad inclusion of 4,000 people from 180 organizations, including people with lived experience, as well as health advocates, researchers, politicians, Indigenous leaders and many others: https://fare.org.au/labelling-campaign/. There are many other aspects of alcohol policy that deserve attention as part of FASD prevention, and the CanFASD Network Action Team on FASD Prevention (pNAT) is pleased to have participants who are interested in actively working towards improved alcohol policy over the coming year.

Community development – Another approach to raising awareness of the disability and its prevention is though involving families, organizations and communities in collective health promotion action. While the pandemic has thwarted most face- to- face community action, the Able2 group in Ontario is organizing a community walk to raise awareness on September 11th in Ottawa. For more information see: https://kitchissippi.com/2021/08/04/able2-on-upcoming-fasd-awareness-walk-pandemic-fundraising/

Promoting connection, respect and awareness is always a win!