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.

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

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

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

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.

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.

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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).

Emerging Approaches to FASD Prevention

One year ago, the Centre of Excellence for Women’s Health released Doorways to Conversation: Brief Intervention on Substance Use with Girls and Women. Since then, there has been a growing interest in expanding work on brief interventions and FASD prevention, to be inclusive of multiple substances and multiple health issues for women, their families and communities.

Here are four innovative ways that brief discussion about alcohol and other substance use is being expanded:

In Sexual Health

Sexual health clinicians are well positioned to deliver brief substance use interventions due to their open, non-judgmental and harm reduction-oriented model of practice. Sexual health providers are able to discuss substance use together with contraceptive use and/or sexually transmitted and blood borne infections [1, 2]. Conversations about substances, sex, and safety can support a woman’s decisions and confidence for change towards improving health in whatever area fits for her.

Linking Discussion of Multiple Substances

Cannabis legalization provides a ‘window of opportunity’ to engage in discussions about alcohol, tobacco, and cannabis use in pregnancy. Discussing what we know and don’t know about cannabis use in pregnancy can now be linked to open conversations about alcohol and other substance use in pregnancy.

Understanding the Link to Adverse Childhood Experiences (ACEs)

Research on ACEs shows how a history of childhood stressors, including physical, sexual, and emotional abuse, may influence alcohol use among adults including pregnant women [3]. Adopting a trauma-informed approach in conversations about alcohol use in pregnancy supports women who experienced childhood adversity with safety, choices, collaboration, self compassion and skills for change.

Advancing Indigenous Wellness Approaches

Holistic, relational, community-based, and culture-led FASD prevention initiatives are key to wellness for pregnant women in Indigenous communities [4]. These interventions address the broad social and structural determinants of health that are associated with substance use and respond to the Truth and Reconciliation Commission Call to Action #33.

References

1. Lane, J., et al., Nurse-provided screening and brief intervention for risky alcohol consumption by sexual health clinic patients. Sexually Transmitted Infections, 2008. 84(7): p. 524-527.
2. Crawford, M.J., et al., The clinical effectiveness and cost-effectiveness of brief intervention for excessive alcohol consumption among people attending sexual health clinics: a randomised controlled trial (SHEAR). Health Technology Assessment, 2014. 18(8): p. 1-48.
3. Frankenberger, D.J., K. Clements-Nolle, and W. Yang, The Association between Adverse Childhood Experiences and Alcohol Use during Pregnancy in a Representative Sample of Adult Women. Women’s Health Issues, 2015. 25(6): p. 688 – 695.
4. Wolfson, L., et al., Collaborative Action on Fetal Alcohol Spectrum Disorder Prevention: Principles for Enacting the Truth and Reconciliation Commission Call to Action #33. International Journal Of Environmental Research And Public Health, 2019. 16(9).

Using e-technology to support maternal-child health

The Hope Project app

With most everyone having a smartphone these days, people are using apps to support their health. There are a few apps directed to pregnant women about their substance use and mental health. Some recent efforts developed together by researchers and health providers show how these apps can be used to offer focused information and support to pregnant women.

A perinatal mental health research project in Alberta, The Hope Project, is exploring how e-technology can be used to support pregnant women with mental health concerns. Dr. Dawn Kingston and her team at the University of Calgary developed an app for screening and treating pregnant women experiencing anxiety and depression. It provides information, support, and help to women in the research study whenever they need it. The project will also look at how this intervention affects post-partum depression and the health of their children.

SmartMom Canada, was developed as part of a study from the University of British Columbia. Through text messaging, Optimal Birth BC provides women in Northern BC with prenatal education endorsed by the Society of Obstetricians and Gynaecologists of Canada (SOGC). Many of these women live in rural areas and may have limited access to prenatal care. Women who enroll in the study complete a confidential survey and then receive personalized text messages that include pregnancy tips, info on health topics, and available resources in their own community.

SmartMom Canada app

Women outside of these studies may find it challenging to find similar apps. Popular pregnancy apps do not offer much info or ideas for resources for women with mental health or substance use issues. One that has been positively evaluated is Text4baby in the U.S. The sponsors partner with national, state, and private organizations and offer local resource information in some states. Also available to Spanish speakers, an evaluation of the app can be found here.

As well, apps are being targeted to health care providers on improving the care they provide. A preconception care app available to physicians provides them with information from the National Preconception Health and Health Care Initiative and makes suggestions for responding to patient questions. Research is being done on using an app to provide motivational interviewing interventions to pregnant women who use substances.

Most apps available on smartphones are directed toward the general population and seek a large user base. Mental health apps and substance use apps that might support prevention, are not designed specifically for women, pregnant or not. And most pregnancy apps focus on fetal growth and “kick counters”, the woman’s weight and blood pressure, and checklists to get ready for a child.

So, while there is an app for everything, they may not an app for everyone. However, healthcare technology is growing at a fast pace, so hopefully we will see more apps in future that can expand FASD prevention efforts.

Related topics:

TEXT4BABY PROGRAM IN THE UNITED STATES: CAN TEXT MESSAGING BE AN EFFECTIVE ALCOHOL BRIEF INTERVENTION? February 2, 2015

HEALTHY PREGNANCY, HEALTHY BABY TEXT MESSAGING SERVICE IN TANZANIA December 17, 2013

Trauma-informed FASD Prevention and Care – Upcoming Webinar

Service providers and FASD prevention advocates are well aware of the intersections of trauma, substance use, and mental health issues as first described by researchers like Lisa Najavits (Najavits, Weiss, & Shaw, 1997). Research from the Women and Co-occurring Disorders and Violence study substantiated what many understood intuitively – that women with substance use problems facing complex life issues are best served through multi-leveled, integrated service models that are trauma-informed, gender-specific, and holistic (Amaro, Chernoff, Brown, Arévalo, & Gatz, 2007; Brown & Melchior, 2008).

There is an upcoming opportunity to learn more about applying these approaches to FASD prevention and care in a webinar on April 18^th at 9:00 am MST. The CSS Learning Series webinar as part of their FASD Learning Series will feature speakers Candice Sutterfield, Lakeland Centre for FASD, and Dr. Peter Choate, Assistant Professor of Social Work at Mount Royal University and clinical supervisor for the Alberta College of Registered Social Workers. They will address both a prevention and supports & services perspective. Sign up here: http://csslearningseries.ca/trauma-informed-fasd-prevention-and-care-registration-2/

Programs in Canada, like Breaking the Cycle and HerWay Home, currently offer integrated programs for/with pregnant and parenting women with substance use issues. Their program frameworks are trauma- and FASD-informed and they offer substance use treatment/support programming as well as needed social services and referrals at a single access point. Program evaluation findings show that relationship building is the key component benefiting women’s growth and supporting the mother-child relationship long-term. (See their evaluations here: Breaking the Cycle and HerWay Home).

In a very recent study undertaken in Ontario, findings from interviews with women participating in integrated programs, described qualities of a therapeutic relationship that helped women improve emotional regulation and executive functioning (Milligan, Usher, & Urbanoski, 2017). Therapeutic relationships that incorporate trust, care, positive regard and a non-punitive attitude can create a safe attachment from which women can apply effective problem solving in all areas of their lives.

Sign up for the webinar and see these earlier posts for more information:

The Mother-Child Study: Evaluating Treatments for Substance-Using Women, March 18, 2015

HerWay Home Program for Pregnant Women and New Mothers in Victoria, BC, February 12, 2013

REFERENCES

Amaro, H., Chernoff, M., Brown, V., Arévalo, S., & Gatz, M. (2007). Does integrated trauma-informed substance abuse treatment increase treatment retention? Journal of Community Psychology, 35(7), 845-862.

Brown, V. B., & Melchior, L. A. (2008). Women with co-occuring disorders (COD): Treatment settings and service needs. Journal of Psychoactive Drugs, SARC SUPPL 5, 365-385.

Milligan, K., Usher, A. M., & Urbanoski, K. A. (2017). Supporting pregnant and parenting women with substance-related problems by addressing emotion regulation and executive function needs. Addiction Research & Theory, 25(3), 251-261. doi:10.1080/16066359.2016.1259617

Najavits, L. M., Weiss, R. D., & Shaw, S. R. (1997). The link between substance abuse and posttraumatic stress disorder in women. A research review. The American Journal On Addictions / American Academy Of Psychiatrists In Alcoholism And Addictions, 6(4), 273-283.

Could prevention efforts be enhanced by study of postnatal clinical interventions designed to reverse FASD-related learning deficits?

Using animal models, scientists at Northwestern University in Chicago were able to reverse learning and memory deficits resulting from exposure to alcohol in utero. The scientists administered thyroxine (a hormone that is reduced in pregnant women who drink and in infants with fetal alcohol spectrum disorder) or metformin (an insulin sensitizing drug that lowers blood sugar levels, which is higher in alcoholics) to rat pups exposed to alcohol in utero, in the 10 days immediately after they were born.  Based on these findings, they will conduct a clinical trial with pregnant women in South Africa.

Dr. Eva Redei, one of the scientists involved in the study believes that such options are necessary for women with alcohol use disorders, or those who drink before they know they are pregnant. In a recent newspaper interview, Dr. James Reynolds at Queen’s University in Canada said he doubts that this will be a cure for FASD, but that studies like this one could give us more clues as to how alcohol affects development.

Other important voices are community-based prenatal program providers and mothers of children with FASD who see that medical interventions, should they be found to be effective, are likely to be only a part of the picture, and that a range of prevention efforts will always be needed.

Whether or not learning and memory deficits can be reversed through hormonal and insulin interventions in the future, there are many other health deficits resulting from alcohol-exposed pregnancies that remain and that may not respond to this treatment (https://www.sciencedaily.com/releases/2016/01/160106091842.htm ).

Consequently, even if this new clinical trial shows positive outcomes, FASD prevention efforts that support women’s decision making about alcohol use, and prevention efforts that influence the social determinants of women’s health will still be needed.

You can read more here:

https://www.eurekalert.org/pub_releases/2017-07/nu-rfa071717.php

 

Discussing alcohol use with women – does the SBIR model need rearranging?

How to discuss alcohol use with women of childbearing age is a topic in women’s health that is getting more attention and focus. Within FASD prevention circles, we have understood that women and their partners may not know about the risks of alcohol consumption during pregnancy or may drink before they realize they are pregnant.  Thus, they benefit from discussion of what they know, what the evidence says and options for action.

Screening, Brief Intervention, and Referral (SBIR) has long been known as an approach to guide clinicians when assessing risky alcohol use. But is the SBIR model the best approach to discussing alcohol with women of childbearing age and their partners? What are the approaches currently used across Canada? How should we discuss alcohol with women and who should do it? What works best according to the evidence?

The Centre of Excellence for Women’s Health (CEWH), the Canadian Centre on Substance Use and Addiction (CCSA), and the University of British Columbia Midwifery Program have teamed up to answer these questions. The Dialogue to Action on Discussing Alcohol with Women project has three high-level objectives: to identify current approaches; to summarize and share the available evidence; and, to promote best practices.

Nancy Poole of CEWH and Audrey McFarlane of CanFASD and Lakeland Centre for FASD at the Dialogue to Action regional meeting in Edmonton.

In order to meet their first objective, project researchers are currently conducting 12 regional meetings across Canada with physicians, midwives, nurses, and service providers in, sexual health clinics, violence against women services, alcohol and drug services, and Indigenous health services.

They are learning what is already being done and sharing what is known about promising practices and existing resources that can guide discussions and referrals. Participants are suggesting resources and tools – such as webinars, guidelines, policies and programs – that will be helpful in conducting meaningful discussions and support in their communities with women who use legal substances – or soon to be legal, like cannabis.

One early emerging idea arising from this project is that “screening” may be currently placed in the wrong location in the mnemonic list of SBIR.  Starting with brief information sharing and support (the relationship first), followed by screening/referral can be more engaging, trauma-informed, collaborative and person-centred. The rearranged approach prioritizes eliciting and appreciating individual needs and perspectives.

So the list might become BISR or even BISBIRT – repeating the conversation about substance use and ideas for action after screening as well as before it.

Participants from a regional meeting in Winnipeg, MB, discuss approaches to discussing alcohol with women that are working in their communities.

This project is one of several projects addressing FASD in Canada being funded by the Public Health Agency of Canada. You can learn more about all the projects here: https://www.canada.ca/en/public-health/news/2017/05/fetal_alcohol_spectrumdisorderincanadanewprojectfunding1.html

Read more:

Conversations on alcohol: Women, their partners, and professionals – April 23, 2017

Preconception Interventions: Trending or Mainstream? – July 21, 2016

Alcohol and FASD: It’s not just about women  – June 6, 2017