Preconception Care to Optimize Health

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


Impact Evaluation Findings from Project Choices in Manitoba

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Project CHOICES is a program in Winnipeg, Manitoba, that works with girls and women of any age who are not currently pregnant, drink alcohol, and are sexually active. The goal of the program is to reduce the risk of an alcohol-exposed pregnancy through choosing healthy behaviours around alcohol and birth control use.

This infographic summarizes changes for participants three months after completing the program.

Project CHOICES is based on motivational interviewing which is a counseling approach that is respectful, non-judgmental and client-centred. Motivational interviewing allows health care providers and clients to explore possible areas of change, discuss strategies that make sense for the client and their life circumstances, and provides encouragement and support.

The program considers three different routes to reducing the risk of an alcohol-exposed pregnancy: (1) reducing alcohol use (2) using effective contraception (3) reducing alcohol use and using effective contraception.

Learn more about the evaluation from Healthy Child Manitoba. Check out the program website to learn more about the program, how to make a referral, and for resources on alcohol, pregnancy and birth control.

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Global Trends in Unintended Pregnancy: Implications for FASD Prevention

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Of the 213 million pregnancies that occurred worldwide in 2012, 40%—about 85 million—were unintended.

A recent study, “Intended and Unintended Pregnancies Worldwide in 2012 and Recent Trends,” by Gilda Sedgh et al. of the Guttmacher Institute found that the proportion of pregnancies that are unintended varied considerably by region.

The highest proportions were in Latin America and the Caribbean (56%) and North America (51%), and the lowest were in Africa (35%), Oceania (37%) and Asia (38%); Europe’s proportion was the closest to the global average (45%).

One of the key recommendations of the study is increased support for contraceptive services worldwide.

These findings have important implications for those interested in preventing alcohol-exposed pregnancies. While most FASD prevention efforts focus on preventing alcohol use during pregnancy, preventing pregnancy while using alcohol is an equally important approach.

For more on this issue, including a brief review of evidence, practice suggestions for health care providers, and resources, visit the Alcohol, Contraception, and Preconception section of the Coalescing on Women and Substance Use website.

Also, see earlier posts:

 

 

 

 

FASD Awareness Campaigns: Creating Effective Messages

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With International FASD Awareness Day just around the corner (on September 9th), many organizations and communities are getting ready by developing awareness materials and planning activities ranging from pancake breakfasts to seminars and training for health professionals to social media activities.

In the past decade, awareness about FASD has increased and in many communities the majority of women are aware that alcohol consumption can cause harm during pregnancy. However, new research and ongoing media coverage and continues to raise questions about whether any alcohol use during pregnancy is okay or whether risk remains the same throughout pregnancy. And many people know very little about FASD in general.

In addition to addressing this type of ambiguity, there are a number of other types of messages that have been shown to be helpful, informative and supportive. Depending on who your audience is (see the infographic above about some different audiences you could consider), some of the other issues to consider in developing FASD prevention messages include:

  • Make sure that messages are balanced and informative. Indistinct or ambiguous messages about the risks of alcohol use during pregnancy should be avoided. Messages like “Think before you drink” or “Alcohol can harm your unborn baby” can be perceived as threatening without helping women place risk into context.
  • Avoid focusing on encouraging women to stop drinking for their baby or suggesting that women who don’t stop drinking are uncaring or irresponsible. This includes messages like “When you drink during pregnancy so does your baby” or messages written on top of pregnant bellies saying “Hey, I’m in here!”  Lessons from the tobacco and pregnancy field indicate that these messages are not effective and can be perceived as shaming and blaming women who are unable to stop drinking during pregnancy due to problems with alcohol dependence.
  • The message that “Fetal alcohol spectrum disorder is 100% preventable” is controversial as alcohol use often happens before a woman recognizes that she is pregnant or can be tied to other serious health and social issues such as poverty and experiences of violence.
  • Don’t forget that preventing pregnancy by supporting accessible and safe contraception is an excellent FASD prevention strategy – it’s not always necessary to focus on alcohol use. For example, a message could say something like “Alcohol and pregnancy don’t mix. If you drink alcohol and are sexually active, make sure you use effective contraception.

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Here are a few resources for starting to think about effective messaging and communication.

  1. Keys to a Successful Alcohol and Pregnancy Communication Campaign – While over a decade old, this 2003 resource from the Best Start Resource Centre in Ontario remains an excellent guide to getting started with thinking through key issues related to alcohol and pregnancy awareness campaigns. Includes facts, tips, ideas, and examples. The Centre also has a range of resources for health professionals and general audiences related to alcohol, pregnancy, and breastfeeding, including Mocktails for Moms and printer-ready handouts in English, French, Arabic, Cree, Ojibway, Hindi, Punjabi, Tamil, Urdu, Simplified Chinese, Spanish and Tagalog
  2. FASD PosterMaker app -This app was designed for health professionals working in Aboriginal and Torres Strait Islander health care settings across Australia so that they can create their own locally relevant and culturally appropriate resources on Fetal Alcohol Spectrum Disorders (FASD).
  3. BC Ministry of Health International FASD Awareness Day Toolkit – Includes planning tools, sample press releases, and FAQs
  4. Alcohol, Pregnancy and Prevention of Fetal Alcohol Spectrum Disorder: What Men Can do to Help – There are a number of ways to engage men in FASD prevention activities. This two-page fact sheet has a dozen suggestions to start thinking about how to create messages and campaigns that view FASD prevention as a shared responsibility.

For more discussion on best practices and controversies related to messaging, see earlier posts:

Economic Evaluation of the Parent–Child Assistance Program in Alberta, Canada

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The Parent–Child Assistance Program (PCAP) began in 1991 at the University of Washington. It is an intensive three-year one-on-one mentoring program for women at high risk of having a child born with FASD.

The primary aim of the program is to prevent future alcohol and drug exposed pregnancies by encouraging the use of effective contraceptive use, by helping women abstain from or decrease their use of alcohol and drugs and by addressing the range of factors that contribute to women’s substance use, including poverty, isolation, and lack of parenting support. The program uses a home visiting/case management approach and is based on principles of harm reduction.

The model has been  replicated and evaluated across North America and has been found to be effective in a number of ways.

A recent study conducted an economic evaluation of the PCAP program in Alberta.  Between 2008 and 2011,  366 women participated in 25 P-CAP programs across the province.

The evaluation estimated that the program prevented approximately 31 (range 20–43) cases of FASD among the 366 clients in a 3-year period which resulted in a cost-benefit of approximately $22 million.

For more on the Parent-Child Assistance Program in Canada, see earlier posts:

References

Rasmussen, C., Kully-Martens, K., Denys, K., et al. (2012). The effectiveness of a community-based intervention program for women at-risk for giving birth to a child with fetal alcohol spectrum disorder (FASD). Community Mental Health Journal, 48, 12–21.

Thanh, N.X., Jonsson, E., Moffat, J., Dennett, L., Chuck, A.W., and Birchard, S. (2014).  An Economic Evaluation of the Parent-Child Assistance Program for Preventing Fetal Alcohol Spectrum Disorder in Alberta, Canada. Administration and Policy in Mental Health and Mental Health Services Research.

 

 

 

FASD Informed Practice for Community Based Programs

FASDInformedPracticeFinalVersionSeptember9-2013_pdf

FASD informed practice can include:

  • An awareness that FASD (diagnosed and undiagnosed) is a reality for many individuals involved with a variety of community-based programs
  • A strong theoretical and practical understanding of the traits, characteristics, barriers, and needs of those affected by FASD
  • A willingness on the part of program staff, including administration, reception, and frontline workers, to participate in ongoing FASD education and training initiatives
  • Agency policies that accommodate the unique needs of individuals living with FASD in order to create a program that works for all participants
  • A respectful and individualized approach to service delivery that recognizes individual strengths

This guide from the College of New Caledonia is designed to assist programs in providing FASD-informed services and supports. The approaches discussed were developed from evidence-based research and from the practical experience of individuals working with women and their families who may be living with FASD.

The guide includes sections on promoting dialogue about alcohol and drug use during pregnancy, contraception, trauma-informed practice, effective group facilitation, strategies for individual support, and examples of exercises that can be used in group programming.

FASD Informed Practice for Community Based Programs can be downloaded from the College of New Caledonia website here.

For more about FASD-informed work at the College of New Caledonia, see an earlier posts:

 

 

Poster Campaign from the Alberta Gaming and Liquor Commission

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The Alberta Gaming and Liquor Commission (AGLC) has a new FASD poster campaign. The AGLC  website reports that the poster will be distributed through liquor stores, healthcare delivery sites, and key provincial stakeholders and describes the poster like this:

“The poster is bold and impactful as it was created to be eye-catching and to grab consumer attention. The message does not place blame nor create an unsupportive environment, but is a visual representation of the fact that choices related to alcohol and pregnancy do matter and can have severe consequences.”

While the poster is not intended to be unsupportive, it is reminiscent of smoking in pregnancy campaigns of the early 1980s. (For more on this issue, see earlier posts here and here). What do you think? Who is the intended audience and what is the poster trying to accomplish?

The Alberta Gaming and Liquor Commission is a member of the FASD Cross Ministry Committee. The FASD-CMC works in co-operation with provincial and community organizations and regional groups to provide a comprehensive and co-ordinated provincial response to FASD.

Denise Milne, Senior Manager in Alberta Health Services and lead of the Provincial FASD Initiative, recently gave an update on FASD prevention activities in Alberta which you can view here.

Denise mentions the development of an FASD Awareness and Prevention Council through the FASD Cross Ministry Committee. She also reports on evaluation findings from Alberta’s 24 mentoring programs (7 are First Nations) based on the Parent–Child Assistance Program (PCAP) (learn more about the PCAP model here). These programs work with about 250 women who are at-risk of having a child with FASD. Evaluation findings show that the program is effective in decreasing rates of welfare use and increasing employment and use of birth control.

For more on FASD prevention in Alberta, see earlier posts:

Do concerns about alcohol use during pregnancy lead women to consider having an abortion?

Research explores whether alcohol use prior to pregnancy awareness affects women’s decision-making

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Most women are aware that alcohol and other substance use can affect an unborn baby. Current medical advice supports abstaining from consuming alcohol during pregnancy as there is no known safe level of alcohol consumption.  However, we also know that approximately 1/3 to half of pregnancies are unplanned. And, in most Western countries, the majority of women drink alcohol. (According to the 2006 Canadian Maternity Experience Survey, 62% of women consumed alcohol in the three months prior to pregnancy. Other studies suggest that over 50% of women ages 18-24 drink at moderate to high risk levels).

As a result, some people have expressed concern or reported anecdotes about women who might seek an abortion due to fear or stress associated with drinking alcohol prior to becoming aware of their pregnancy and the harm they might have caused their baby.

A study published last year by Roberts et al called “Alcohol, Tobacco and Drug Use as Reasons for Abortion” examines some of these questions for the first time. The research team surveyed 956 women accessing abortion services in the USA to identify whether alcohol, tobacco or other drug use in the month prior to pregnancy awareness contributed to their decision to end their pregnancy. 25 women (2.6%) identified alcohol as a reason for seeking the abortion.

The majority (84%) of women who identified alcohol as a reason for seeking an abortion reported drinking at binge levels (5+ standard drinks per occasion) or having experienced alcohol-related problems such as blackouts. Around half of the women who reported binge drinking as a reason for seeking an abortion were binge drinking more than once a week and the median number of binge drinking sessions was five.

This study can be seen as reassuring in that a small number of women considered their alcohol use as a factor in ending an otherwise wanted pregnancy. It does raise questions about how we talk about FASD and the framing of messages about the potential harms of alcohol use during pregnancy.

Current guidelines by obstetrics and gynecology professional associations in Canada and the USA explicitly state that low levels of alcohol use in early pregnancy is not an indication to end a pregnancy.

For more on related topics, see earlier posts:

References

O’Leary, C. (2012). Alcohol and Pregnancy: Do Abstinence Policies Have Unintended Consequences? Alcohol and Alcoholism, 47(6):638-9. doi: 10.1093/alcalc/ags094

Roberts, S.C.M., Avalos, L.A., Sinkford, D., and Foster, D.G. (2012). Alcohol, Tobacco and Drug Use as Reasons for Abortion. Alcohol and Alcoholism, 47(6): 640–648. doi: 10.1093/alcalc/ags095. Download free full-text here.

Society of Obstetricians and Gynecologists of Canada. (2010). Alcohol Use and Pregnancy: Consensus Clinical Guidelines. Journal of Obstetrics and Gynaecology Canada, 32(8): S1-S32.

Walker, M., Al-Sahab, B., Islam, F., & Tamim, H. (2011). The epidemiology of alcohol utilization during pregnancy: an analysis of the Canadian Maternity Experiences Survey (MES). BMC Pregnancy and Childbirth, 11(1), 52. doi:10.1186/1471-2393-11-52. Download free full-text here.

Handbook for Aboriginal Alcohol and Drug Work from Australia

Handbook Cover

“The Handbook for Aboriginal Alcohol and Drug Work is a practical tool written for Aboriginal drug and alcohol workers, mental health workers and others working in this field. It offers a detailed look at alcohol and drug work from clinical, through to prevention, early intervention and harm reduction. This handbook is also likely to help people working to improve policy and those advocating for change.

The idea for it came from workers all over Australia. They told us that they needed an easy to use handbook that can help them respond to the range of alcohol and drug issues they face every day. They also told us that such a book needs to take into account the complex challenges facing workers when helping clients, their families and, sometimes, whole communities.”

This plain language, evidence-based guide was created in partnership between the University of Sydney and Aboriginal and non-Aboriginal agencies and health professionals. Four of the six editors are Aboriginal.

It covers alcohol and drug use as well as a whole range of other issues, including child protection notifications, legal issues, working with clients without housing, mental health and polydrug use, and community-wide approaches.

Chapter 2 focuses on alcohol and Chapter 16 focuses on Special situations, settings, and groups, including pregnancy, breastfeeding and early childhood. It discusses the use of brief intervention and counselling approaches in the context of alcohol and pregnancy. It also has sections covering Neonatal Abstinence Syndrome, Alcohol use in pregnancy and Foetal Alcohol Spectrum Disorders.

The handbook was first distributed to alcohol and drug professionals from around Australia at the National Indigenous Drug and Alcohol Conference in Western Australia in June 2012.

The project started in 2010 with a grant from the Foundation for Alcohol Research and Education (FARE) and continued with the support of the NSW Ministry of Health.

The handbook is available online.

Unintended Pregnancies and Alcohol Consumption during Pregnancy in the United States

Making the link between unintended pregnancies and FASD prevention

The Centers for Disease Control and Prevention (CDC) in the United States released two reports this month with new data on alcohol consumption during pregnancy and unintended pregnancies. It’s interesting to take a look at these reports side-by-side as they suggest completely different target groups for FASD prevention activities.

The first report looked at alcohol use and binge drinking among women of childbearing age. The researchers found that approximately 7.6% (or 1 in 13) of pregnant women consume alcohol during pregnancy and that 1.4% of pregnant women binge drink. Interestingly, non-pregnant women and pregnant women had similar patterns of binge drinking: about three times per month and approximately six drinks on an occasion.

Among pregnant women, the highest prevalence estimates of reported alcohol use were among those who were aged 35–44 years (14.3%), “white” (8.3%), college graduates (10.0%), or employed (9.6%).

In 2005, the Surgeon General issued an advisory urging women who are pregnant or who might become pregnant to abstain from alcohol use. Currently, the CDC advises: “Because no safe level of alcohol during pregnancy has been established and alcohol is known to cause birth defects, developmental disabilities, and other adverse pregnancy outcomes, women who are pregnant or who might become pregnant should refrain from drinking alcohol.”

It’s the last part of this advisory targeted at “women who might become pregnant” that leads us to the second report.

Generally speaking, it is believed that 1/3 to 1/2 of pregnancies are unintended. This report found that about 37% of births in the United States were unintended at the time of conception. While this statistic hasn’t changed much since the early 1980s, the groups with the highest rates of unintended pregnancies have changed (you can take a closer look at the report for more – see the link below).

Unintended pregnancies include both pregnancies that are unwanted, and those are mistimed, meaning the woman said she wanted to become pregnant at some point, but not at the time she did.

There’s a lot of reasons why a women becomes pregnant unintentionally and contraception use is one of them. The researchers found that 40% of women were using contraception and 60% were not. The researchers asked women who were not using contraception at the time they conceived about their reasons. They found that:

  • 35.9 percent said they did not think they could get pregnant
  • 23.1 percent said they would not mind if they became pregnant
  • 17.3 percent said they had not expected to have sex
  • 14.3 percent said they were worried about the side effects of using birth control

In terms of men, 8% said their male partner did not want to use birth control himself, and 5.3 percent said their male partner did not want them to use birth control.

So, it’s interesting to think about, right?

  • 52% of women of childbearing age consume alcohol
  • 37% of pregnancies are unintended (which means these women were unlikely to change their alcohol consumption)
  • Of women who become pregnant unintentionally, 60% were not using contraception.

These data suggest that we need to be looking at alcohol use, especially risky alcohol use like binge drinking, way before conception. It also suggests that many women need additional support around their fertility and finding contraception that works for them (and that perhaps their male partners might want to get involved in some of these issues??)

References

Marchetta, C.M., Denny, C.H., Floyd, L., Cheal, N.E., Sniezek, J.E., McKnight-Eily, L.R. (2012). Alcohol Use and Binge Drinking Among Women of Childbearing Age — United States, 2006–2010. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report (MMWR), 61(28): 534-538.

Mosher, W.D., Jones, J. and Abma, J.C. (2012). Intended and Unintended Births in the United States: 1982–2010. National Health Statistics Reports, No. 55. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.