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Because alcohol and tobacco have long been legal substances, there is a lot of evidence about their use during the preconception, pregnancy and perinatal periods. With the legalization of cannabis in Canada, new research on cannabis use may begin to fill the existing evidence gaps and better define its risks.

Because of its illegal status, women may have been reluctant to report using cannabis during pregnancy unless it was being used medically, and research ethics may have prohibited its study. Consequently, much of what we know about cannabis use in pregnancy has come from data gathered during studies on alcohol and tobacco. That is why it now makes sense to link the work of all three substances.

For instance, research shows that women who use cannabis during pregnancy are more likely to smoke cigarettes and use alcohol.1 As well, co-use of tobacco and cannabis is associated small head circumference and may increase other birth defects (cardio, musculoskeletal, and gastrointestinal) compared to no-use and single-use groups.2 This finding of association should be interpreted with some caution based on the number of limitations of the study. Still, it does underscore the need for more robust research in order to understand the association.

Researching all three substances allows for understanding the “clustering of risks” and the interactions between those risks in a way that targeting individual substances cannot do.3 By looking at the clustering of risk as described by researchers, holistic prevention efforts can target social determinants of health that affect poly-substance use.

Linking the findings on the three substances allows researchers to parse out the differences among those who use substances in pregnancy, and the clusters of risk for the substances they use. That will help to further prevention efforts in messaging, discussing substance use with women and their partners, and supporting women with holistic and safe approaches.

References

1. Ko, J.Y., Tong, V.T., Bombard, J.M., Hayes, D.K., Davy, J., & Perham-Hester, K.A. (2018). Marijuana use during and after pregnancy and association of prenatal use on birth outcomes: A population-based study. Drug and alcohol dependence, 187, 72-78.
2. Coleman-Cowger, V.H., Oga, E.A., Peters, E.N., & Mark, K. (2018). Prevalence and associated birth outcomes of co-use of Cannabis and tobacco cigarettes during pregnancy. Neurotoxicology and teratology, 68, 84-90.
3. Passey, Megan E. et al. (2014). Tobacco, alcohol and cannabis use during pregnancy: Clustering of risks. Drug & Alcohol Dependence, Volume 134, 44–50. https://www.sciencedirect.com/science/article/pii/S0376871613003700#bib0185

For more on these topics, see earlier posts:

DISCUSSING ALCOHOL USE WITH WOMEN – DOES THE SBIR MODEL NEED REARRANGING? October 4, 2017
ALCOHOL, COCAINE, MARIJUANA, AND CIGARETTE USE DURING PREGNANCY: LOOKING AT RELATIVE HARMS March 17, 2014

A newly published book entitled Mothers, Addiction and Recovery underscores the value of focusing on maternal identity and meaning for supporting women with children through addiction and recovery. By bringing together the voices of women with lived experiences, as well as program practitioners, policy makers, and researchers from across Canada, the editors illustrate the gendered nature of addictions (including gambling, food and smartphones) and the value of harm reduction and holistic approaches to healing and recovery.

Members of this Prevention Network Action Team contributed articles to the book. In “Mothering and Mentoring: The PCAP Women’s Quilt”, Dorothy Badry, Kristin Bonot, and Rhonda Nelson describe the quilt project undertaken by mentors and program participants from the Parent Child Assistance Program (PCAP) project in Alberta. Named “Woven Together”, the quilt is a visual expression of the powerful relationship ties that the women and mentors created together. As well, the article offers a historical perspective on FASD and FASD prevention efforts.

In a chapter entitled “Beyond Abstinence: Harm Reduction during Pregnancy and Early Parenting” Lenora Marcellus, Nancy Poole, and Natalie Hemsing reflect on the historical concern around substance use during pregnancy and how important it is, now, to bring a gendered and harm reduction orientation to our responses. They conclude that, regardless of the substances used, harm reduction approaches address the complex life circumstances of women, such as culture, trauma, connection to children, and practical socio-economic realities. They describe emerging and established programs that use harm-reduction and trauma-informed approaches in order to provide tailored systems of care that are non-punitive, responsive and effective for women and families. Many of these programs have been featured in this blog (see below).

This book is published by Demeter Press and features many other articles that address the experience of mothering within the context of addictions. Although the voices of women with lived experiences are included in part, the editors, Wendy E. Peterson, Laura Lynn Armstrong, and Michelle A. Foulkes, regretfully acknowledge that the book is missing the unique perspectives of Indigenous women.

For related information, see these earlier posts:

REACHING AND ENGAGING WOMEN: WHAT WORKS AND WHAT’S NEEDED May 15, 2017

TARGETING STIGMA AND FASD IN MANITOBA June 26, 2017

HOUSING IS KEY COMPONENT TO WOMEN’S RECOVERY August 19, 2017

DEVELOPING AN INDIGENOUS APPROACH TO FASD PREVENTION IN BC’S FRASER SALISH REGION December 11, 2017

ALBERTA’S PCAP WOMEN’S QUILT: “CREATING A BOND . . . BUILDING A RELATIONSHIP” April 22, 2016

WEBINAR JUNE 23 – WORKING WITH PREGNANT AND PARENTING WOMEN: LEARNINGS FROM HERWAY HOME June 16, 2016

HARM REDUCTION AND PREGNANCY: COMMUNITY-BASED APPROACHES TO PRENATAL SUBSTANCE USE IN WESTERN CANADA February 26, 2015

THE MOTHER-CHILD STUDY: EVALUATING TREATMENTS FOR SUBSTANCE-USING WOMEN March 18, 2015

THE MOTHERING PROJECT/MANITO IKWE KAGIIKWE IN WINNIPEG, MANITOBA May 1, 2015

FASD PREVENTION AND SOCIAL DETERMINANTS OF WOMEN’S HEALTH: ASSESSING THE EVIDENCE March 5, 2012

Sheway is well-known in Canada for its success in providing wrap-around services for pregnant and newly parenting women who are dealing with complex personal and social circumstances. It is trauma-informed, women-centred, culturally responsive and uses a harm reduction approach with a focus on connection with self and others. Women and their children can remain in the program up to 18 months post-partum. Last December, Lenora Marcellus, University of Victoria, and Sheway published findings to their study on how women make the transition from Sheway to living on their own – Supporting Families at Sheway and Beyond. Additionally, Dr. Marcellus has published a journal article:

Marcellus, L. (2017). A grounded theory of mothering in the early years for women recovering from substance use. Journal of Family Nursing. E-print ahead of press. 

In order to learn what elements of a positive transition could be identified and built upon, they followed 18 women for 3 years after leaving Sheway. These women faced multiple obstacles in this transition process with the overarching theme being “holding it together.” Their daily efforts are explored in these 3 ways:

Download Sheway Report

Restoring Self: gaining recovery and taking care of self, reconnecting with self and others, and rebuilding trust and credibility.

Centering Family: parenting their children, preserving a routine, dealing with partners, and handling custody issues.

Creating  Home: “chasing housing”, having to take whatever housing is available even if inadequate, and maintaining not only a physical space but a feeling of home for the family

While acknowledging the value for pregnancy and postpartum support as most often provided in maternity programs, their findings underscore that secure housing is a key component to a successful transition for women and their families. Yet, although housing is important to the overall health of women and their families, the choices they must make often result in a double bind. For example, women often are faced with choosing between affordable housing that is far from supports versus more expensive housing that is near supports. Some women must choose between staying in an unsafe relationship or losing housing. As well, some women must accept inadequate housing because of their substance use history, which serves to undermine their recovery and their maintaining custody of their children.

“Poor housing was identified by women as a potential trigger to relapse in their recovery.” – [1] p. 39

Complete findings are detailed within the report and recommendations are framed within the Levels of Prevention model developed by this prevention network.  Among the research team recommendations is to extend the time women can stay in the program in order to solidify recovery, supports and resources. As well, they stress that housing needs to be a core component of intensive, integrated maternity programs.


For more on these topics, see earlier posts:

HOLISTIC AND SPECIALIZED SUPPORT FOR PREGNANT WOMEN: LEVEL 3 PREVENTION, November 21, 2016
THE MOTHER-CHILD STUDY: EVALUATING TREATMENTS FOR SUBSTANCE-USING WOMEN, MARCH 18, 2015
SUPPORTING PREGNANT AND PARENTING WOMEN WHO USE SUBSTANCES: WHAT COMMUNITIES ARE DOING TO HELP, OCTOBER 1, 2012
HERWAY HOME ‘ONE-STOP ACCESS’ PROGRAM IN VICTORIA SET TO OPEN, MAY 20, 2012
“NEW CHOICES” FOR PREGNANT AND PARENTING WOMEN WITH ADDICTIONS, JANUARY 9, 2012
TORONTO CENTRE FOR SUBSTANCE USE IN PREGNANCY (T-CUP), DECEMBER 19, 2011
CLINICAL WEBCAST ON BREAKING THE CYCLE PROGRAM: SEPTEMBER 20, 2011, AUGUST 2, 2011

  1. Marcellus, L., Supporting families at Sheway and beyond: Self, recovery, family home. 2016, Sheway: Vancouver, BC.

 

why-do-girls-and-women-drinkThe Washington Post recently featured an article on the normalisation of heavy drinking for women. Citing targeted advertising and multiple media, particularly to girls on social media, the article outlines the dangers in this trend of treating alcohol as a lifestyle rather than a drug. The obvious dangers are that normalising heavy drinking will increase the number of alcohol-exposed pregnancies and have a negative impact on girls’ and women’s health. Advertising exploits the positive connections women seek with each other, making it about drinking together and promoting it on t-shirts, cups, cards and even wine labels.

The liquor industry is attempting to link drinking with gender equality. But there is nothing equal or liberating about the risks women and girls face, or the distain that is heaped upon them for drunkenness. A recent article in the Daily Mail supported public shaming of binge drinking by young women in particular, and featured numerous denigrating photos of them on New Year’s Eve. Many pointed out the hypocrisy of moralising (Suzanne Moore, The Guardian). A different dialogue is needed: one that focuses on facts, health, education, and creates platforms of conversation and support.

It’s science not sexism that reveals the risks and consequences of heavy drinking for women and girls, and ways to reduce harm. We have learned why women may drink, the effectiveness of non-judgmental approaches to reducing harm, and best practices and policies for promoting health. The facts are not as confusing as some suggest and by focusing on them, we can counter normalising and moralising.

  • Women’s bodies process alcohol differently, so woman’s alcohol level will be higher than a man drinking the same amount. Canada’s low-risk drinking guidelines reflect this sex difference.girls-alcohol-pregnancy-picture
  • Men, in general, are riskier drinkers than women as evidenced by rates of alcohol-related injury and mortality, but women have more chronic health risks related to heavy drinking (Wilsnack & Wilsnack, 2013).
  • Beyond the risk of addiction, Jennie Cook’s research found a causal link between drinking and at least 7 forms of cancer for both sexes (Connor, 2017).
  • Claims of protective factors for cardiovascular disease are coming under scrutiny and skepticism even as these claims remain a core industry research topic and argument for drinking (Chikritzhs, Fillmore, & Stockwell, 2009)
  • How and when we present the facts of drinking alcohol to women and their partners makes a difference to the health of women and their families (See 10 Fundamental components of FASD Prevention from a women’s health determinant perspective).
  • Prevention of alcohol harms requires a tiered response in policy, practice, and messaging (See FASD Prevention: Canadian Perspectives)
  • Comprehensive and integrated programs that build relationships work best for supporting women in making healthy choices for themselves and their families (See Mothercraft’s Mother-Child Study)

References

Chikritzhs, T., Fillmore, K., & Stockwell, T. I. M. (2009). A healthy dose of scepticism: Four good reasons to think again about protective effects of alcohol on coronary heart disease. Drug and Alcohol Review, 28(4), 441-444. doi:10.1111/j.1465-3362.2009.00052.x

Coalescing on Women and Substance Use. http://coalescing-vc.org/virtualLearning/section2/documents/GirlsAlcoholPregnancyinfographic7.pdf

Connor, J. (2017). Alcohol consumption as a cause of cancer. Addiction, 112(2), 222-228. doi:10.1111/add.13477

Wilsnack, R. W., & Wilsnack, S. C. (2013). Gender and alcohol: consumption and consequences. In P. B. Peter Boyle, Albert B. Lowenfels, Harry Burns, Otis Brawley, Witold Zatonski, Jürgen Rehm (Ed.), Alcohol: Science, policy and public health (pp. 153-160). Oxford, England: Oxford University Press.

 

 

The World Health Organization’s regional office for Europe has published Prevention of harm caused by alcohol exposure in pregnancy: Rapid review and case studies from Member States.

who-coverIn this report it is stated that Europe has the highest level of alcohol consumption in the world, and that the gender gap in drinking, and in binge drinking, among young people has narrowed.

Looking over the past decade, the report features a review of 29 research studies and details current FASD prevention efforts of Finland, Germany, Lithuania, Luxembourg, Norway, Poland, Slovenia and Sweden. Studies included in the report were based on Recommendation 2 of the WHO Guidelines for the identification and management of substance use and substance use disorder in pregnancy, which calls for prevention of alcohol consumption in the general population of pregnant women through brief interventions. Consequently, the review excluded studies of alcohol-dependent women.

For women who may become pregnant, interventions related to both risky drinking and contraception were reviewed, such as CHOICES, EARLY and BALANCE.

For pregnant women, interventions to abstain from or reduce alcohol use, or to raise awareness were reviewed. Two of the studies with pregnant women included their partners and showed positive results regarding women reducing their drinking and partners supporting non-drinking.

Case studies of prevention efforts from the 8 profiled countries describe national awareness campaigns; screening and specialized treatment in clinical practice guidelines; national strategy/policy planning and implementation; and post-partum support including for those affected by FASD.   The report features a table that illustrates country-specific levels of FASD awareness, which can assist in developing focused strategies.

For more on related topics, see earlier blogs:

DANISH CAMPAIGN SUGGESTS THAT EVERYONE “STICK A CORK IN IT” ON OCTOBER 11TH, October 11, 2012

SPECIALIZED TREATMENT AND CARE FOR PREGNANT WOMEN WITH SUBSTANCE ABUSE PROBLEMS AND THEIR CHILDREN IN HAGA, GOTHENBURG, SWEDEN, November 15, 2012

WORLD HEALTH ORGANIZATION RELEASES THE FIRST EVIDENCE-BASED GLOBAL GUIDELINES TO PREVENT AND TREAT SUBSTANCE USE BY PREGNANT WOMEN, April 28, 2014

GLOBAL STATUS REPORT ON ALCOHOL AND HEALTH 2014 – WORLD HEALTH ORGANIZATION, July 24, 2014

PLANNING AND IMPLEMENTING SCREENING AND BRIEF INTERVENTION FOR RISKY ALCOHOL USE: A STEP-BY-STEP GUIDE FOR PRIMARY CARE PRACTICES FROM THE CDC, August 4, 2014

HOLISTIC AND SPECIALIZED SUPPORT FOR PREGNANT WOMEN: LEVEL 3 PREVENTION, November 21, 2016

FASD ANNOTATED BIBLIOGRAPHY 2015, PART 3

FASD Prevention: An Annotated Bibliography of Articles Published in 2015 organizes articles based on the four levels of prevention. 2015 BibliographyWe’ve been featuring some of those articles and in this post we narrow in on Level 3 FASD prevention efforts – specialized holistic support available to pregnant women with alcohol and other health or social problems. Following are a few of the bibliography articles with that research focus.

Two studies from South Africa underscore the interconnections of alcohol use in pregnancy and the benefits of integrated and holistic services for pregnant women. A large study done in Cape Town, randomly assigned all pregnant women in 24 low-income neighbourhoods either to standard care or to a home-visiting intervention. In total over 1,000 mothers were assessed during pregnancy and at 18 and 36 months post-partum with positive findings for those receiving the home-visiting intervention. 4-levels-fasd-preventionThe authors find that a significant relationship exists over time between alcohol use, partner violence and depression, and they recommend integrated interventions [1]. Similarly, a case management intervention for 67 pregnant women using Motivational Interviewing, Community Reinforcement Approach and life management reduced heavy drinking in pregnancy [2].

Marcellus, MacKinnon et al. through their work with the HerWay program in BC, Canada, “reenvision” success when working with pregnant women with problematic substance use. They identify a holistic range of indicators for success, not only for program participants, but for service providers, community partners and system leaders [3]. This kind of harm-reduction model is getting more attention in the USA. Kramlich & Kronk reviewed six such programs over the last 10 years and conclude that “comprehensive, integrated multidisciplinary services for pregnant women with substance use disorder aimed at harm reduction are showing positive results.”[4]

Torchalla, Linden et al. conducted interviews in the Downtown Eastside of Vancouver, Canada, with 27 pregnant or post-partum women seeking harm-reduction services. They found that multiple forms of trauma were pervasive, ongoing, and reinforced in most areas of the women’s lives. Yet, most of the women did not want trauma-specific counseling when offered it. This underscores, according to the authors, the need for multi-focused, trauma-informed, harm-reduction interventions that broaden their focus to include gender-based violence and human rights [5].

Whitaker provides an overview of the World Health Organization (WHO) guidelines on substance use during pregnancy [6]. The author identifies some of the limitations of the guidelines including effectiveness of varying treatment approaches, knowledge gaps, and ethical issues, yet calls the guidance essential reading for practitioners working with women, children and families where substance use is involved.

Findings show that relational, holistic/integrated, and trauma-informed approaches are effective ways to support substance using women and their families. Yet, training, education and support of practitioners who work with them are vital. Additionally, more research in a number of specific areas is needed.

Find out more about these journal articles as well as articles for all four levels of FASD prevention in The Annotated Bibliography.

REFERENCES

  1. Rotheram-Borus, M.J., et al., Alcohol use, partner violence, and depression: A cluster randomized controlled trial among urban South African mothers over 3 years. American Journal of Preventive Medicine, 2015. 49(5): p. 715-725.
  2. de Vries, M.M., et al., Indicated Prevention of Fetal Alcohol Spectrum Disorders in South Africa: Effectiveness of Case Management. International Journal Of Environmental Research And Public Health, 2015. 13(1).
  3. Marcellus, L., et al., Reenvisioning success for programs supporting pregnant women with problematic substance use. Qualitative Health Research, 2015. 25(4): p. 500-512.
  4. Kramlich, D. and R. Kronk, Relational care for perinatal substance use: A systematic review. MCN, the American Journal of Maternal Child Nursing, 2015. 40(5): p. 320-326.
  5. Torchalla, I., et al., “Like a lots happened with my whole childhood”: violence, trauma, and addiction in pregnant and postpartum women from Vancouver’s Downtown Eastside. Harm Reduction Journal, 2015. 12(1): p. 1-10.
  6. Whittaker, A., Guidelines for the Identification and Management of Substance Use and Substance Use Disorders in Pregnancy. Drug & Alcohol Review, 2015. 34(3): p. 340-341.

The Canadian Centre on Substance Abuse (CCSA) is marking November 13-19 as National Addictions Awareness Week. Across Canada, organizations like CEWH and CanFASD are joining with CCSA to bring attention to problematic substance use in Canada. We are highlighting the imbalance between the societal, health and economic costs that substance use problems/addiction brings, and the funding provided for treatment and harm reduction services/supports.

dtnaaw-03-403x213-enCCSA has been a partner in our efforts to explore how addiction can make it difficult to stop alcohol use during pregnancy, and how women-centred approaches are needed in prevention, harm reduction and treatment. You can help us and the CCSA in promoting treatment, highlighting existing barriers, and finding solutions by supporting this campaign. Download the NAAW Toolkit to get ideas for social media postings and organization activities. You can also join the dialogue over social media by following @CCSACanada and using the hashtag #NAAWCanada.

See these earlier blog posts on addictions or “Search the Blog” on the left of this page:
Honouring our Strengths: Culture as Intervention in Addictions Treatment, June 5, 2014
Young Women United: Campaign to Increase Access to Care and Treatment for Pregnant Women with Addictions, February 18, 2014

For the last four years, HerWay Home in Victoria, BC, has been providing outreach, medical and social services to pregnant and parenting women with difficult lives in a one-stop supportive environment. On June 23 from 9:00-10:00 a.m. PST, there will be a free webinar to share the results of a first-phase evaluation of HerWay.

Deborah Rutman and Carol Hubberstey of Nota Bene Consulting, and Nancy Poole of BC Centre of Excellence for Women’s Health will discuss lessons learned and promising practices, and lead a discussion on working with pregnant and parenting women affected by substance use, violence and mental health issues. With its child-focused, women-centred and family focused approach, HerWay Home encourages positive parenting and healthy outcomes for children and women.

Click here for more information and register by June 20th at http://fluidsurveys.com/surveys/bccewh/herway-home-evaluation-webinar/

To learn more about HerWay home and similar programs, see these previous postings:

 

NDARC Guide

This new resource from the National Drug & Alcohol Research Centre, University of New South Wales, Australia, is designed for all primary health care professions who see women in a broad range of health care service settings during the course of their practice.

The best practices guide builds on the evidence for providing coordinated, supportive and comprehensive care to pregnant women who use substances by providing a model for reducing the harm from alcohol and substance for women and their babies. See page 12 of this guide for a clearly charted overview of how physicians and other health care practitioners can support withdrawal, do psycho-social and nutritional interventions, and address barriers to care for pregnant women.

The model acknowledges the interconnections that impact a woman’s use of substances during pregnancy – including domestic violence, mental health, smoking, and stigma – and provides a guide for identifying risk and next steps for further assessment, support and/or treatment. See page 9 for a view of how identification differs for women who are pregnant, planning a pregnancy, or not planning a pregnancy.

It also moves beyond normal referral and coordination practices by using a holistic assessment process and designating a case coordinator or clinical lead to ensure “assertive follow-up.” Assertive follow-up consists of: making sure women are supported during pregnancy and birth; keeping mothers and their babies in the hospital so that post-birth assessments for mother and child can be done and plans for support and services are in place; providing breastfeeding, safe sleeping, parenting skills and contraception support; as well as, interfacing with partners, family members, and community agencies in support of the woman and her child.  See page 16 for more discussion on assertive follow-up and pages 19-20 for “Addressing barriers to care”.

Although the extensive resources that are included in this guide are geared for practitioners in Australia, many of them provide topic-specific information that practitioners everywhere may find helpful. See pages 24-27 for website links.

For more on screening in primary care settings, see previous posts:

For more on FASD prevention in Australia, see previous posts:

 

 

 

 

 

FASD Conference 2

Marsha Wilson, Nancy Poole and Dorothy Badry at the 7th National Biennial Conference on Adolescents and Adults with Fetal Alcohol Spectrum Disorder (FASD). Session E3: Developments in Prevention of FASD – The Work of the Can FASD Prevention Network Action Team

At the 7th National Biennial Conference on Adolescents and Adults with FASD in Vancouver on April 9, 2016, Nancy Poole and Dorothy Badry described the work of CanFASD’s Prevention Network Action Team (pNAT).  They provided examples of the pNAT’s work on:

  1. Network building – Sharing expertise and skills through a network of researchers, policy analysts, clinicians, community-based service providers and advocates dedicated to FASD prevention
  2. Research – Building multidisciplinary research teams, developing research proposals, and conducting research
  3. Collaborative knowledge exchange – Developing and implementing strategies for moving “research into action” such as through workshops, curricula development for health and social service professionals, and policy analysis
  4. Influencing policy and service provision  Guiding service and policy improvements with governments and communities

Given the conference focus on adolescents and adults with FASD, the 2011 research led by pNAT member Deborah Rutman on prevention with girls and women with FASD and substance use problems was highlighted.   Treatment and support with girls and women who live with FASD is one of the least researched areas of FASD prevention.

A list of FASD prevention resource materials developed by pNAT members was provided. Reports and infographics that summarize research, and thereby support research-to-practice and -policy are included below.

LINKS

7th National Biennial Conference on Adolescents and Adults with FASD

Research on prevention with girls and women with FASD

CanFASD  – description of the pNAT

FASD Prevention Resources Spring 2016

FASD Resources

Overview: Four Levels of FASD Prevention

Information Sheet: What Men Can Do To Prevent FASD

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