The Prevention Network Action Team on FASD Prevention from a Women’s Health Determinants Perspective (pNAT)

In Canada, FASD prevention advocates work together to link up the local, provincial and national efforts through a virtual prevention research network, which receives financial support from the Canada FASD Research Network (CanFASD). Recently CanFASD refreshed their website, so national action on prevention is profiled. See https://canfasd.ca/topics/prevention/

The Prevention Network Action Team on FASD Prevention from a Women’s Health Determinants Perspective (pNAT) has four objectives. To advance prevention research, the pNAT builds multidisciplinary research teams, which develop research proposals, and conduct research, including evaluation research.  A second objective is to develop and implement strategies for moving “research into action”, for example through preparing and delivering workshops and curricula (both online and offline), and preparing and distributing policy briefs and reports. A third objective is to influence policy and service provision by proactively and collaboratively working with governments and communities to identify and implement service and policy improvements. It is through the fourth objective of networking and networked learning, that the other objectives are achievable. A virtual, national network becomes a location for sharing knowledge, expertise and skills.

The participants in the Canadian pNAT are inclusive of researchers, service providers,

This document about 10 fundamental components of FASD prevention was one of the first documents that the pNAT members wrote together, ten years ago now
https://canfasd.ca/wp-content/uploads/2016/09/ConsensusStatement.pdf

health system planners, policy analysts, community based advocates and (where possible) mothers with lived experience. To achieve this participation, the pNAT employs a virtual community of inquiry (vCoI) model, supplemented by face-to-face meetings often held in conjunction with national and international conferences. Through the vCoI, participants are able to voluntarily attend monthly webmeetings to:

• Share updates on their work;
• Learn of recent additions to the evidence on FASD prevention;
• Discuss research, service provision and advocacy developments undertaken by members and by others in Canada; and
• Plan collective action.

In this way, participants learn together about FASD prevention, and are able to situate their own work within the field.

The community of inquiry framework developed by Garrison and colleagues (2003) provides the foundational, evidence-based design of the virtual community, and grounds it as a ‘learning’ one. In communities of inquiry, people construct meaning through epistemic engagement, as learners, teachers and social connectors (Shea & Bidjerano 2009). In key ways this virtual learning community model reflects the approach that service providers are finding helpful in interactions with mothers and families: i.e. as both teachers and learners, in relationships that prioritize safety, resilience and connectedness.

In addition to the monthly virtual community meetings, the pNAT uses this blog to share outwardly some of the key issues identified in the virtual community.  Visit the https://canfasd.ca/topics/prevention/ location to learn more about the pNAT and its many activities.

Garrison, D. R. and T. Anderson (2003). E-Learning in the 21st Century: A framework for research and practice. New York, NY, Routledge Falmer.

Shea, P., & Bidjerano, T. (2009). Community of inquiry as a theoretical framework to foster “epistemic engagement” and “cognitive presence” in online education. Computers & Education, 52(3), 543-553.

Addressing Stigma – Acting Collaboratively

Key challenges in FASD prevention are the stigma directed to pregnant women and new mothers who use alcohol and other substances, and the fear of having children removed from mothers’ care if they report their use and/or seek help.  A new resource, in toolkit format,  Mothering and Opioids: Addressing Stigma – Acting Collaboratively addresses these long standing dilemmas for women and for service providers.

This toolkit provides tools, worksheets, and factsheets to aid substance use and child welfare workers in building capacity to offer mother-child centred, trauma informed, culturally safe, and harm reduction-oriented services and policies. The toolkit’s four sections each address a specific area or need in service delivery and provision:

1. Addressing Stigma in Practice

The first section examines how women who use opioids experience stigma and includes tools for assessing potentially stigmatizing practices. This section also includes a script for responding constructively to coworkers’ stigmatizing behaviour arising from the work of Lenora Marcellus and Betty Poag, as well as a factsheet entitled “10 Things Pregnant and Parenting Women Who Use Substances Would Like Practitioners to Know” created by women with lived experience accessing services at HerWay Home in Victoria BC.

2. Improving Programming and Services

The second section describes how stigma relates to the barriers that women face. It identifies promising practice and policy responses that address stigma and health, substance use, and child protection concerns. Tools are provided to facilitate integrating promising approaches into our responses, and to identify ways in which barriers can be overcome. It honours and advances the differing roles of substance use services and child welfare services in supporting women and children, as well as evidence informed shared approaches (See diagram from page 21)

3. Cross System Collaboration and Joint Action

The third section includes information and tools to facilitate cross-system collaboration. Collaboration between the child welfare and substance use fields provides an opportunity to improve child safety and support the recovery of parents. Cohesive working relationships between these sectors can foster advocacy, consultation, system navigation, safety planning, and streamlined referrals. In this, as in all sections there are resources that focus on Indigenous approaches to child welfare and substance use.

4. Policy Values

The final section discusses policy matters, and how defining and affirming policy values can clarify our work in both systems of care. This section emphasizes viewing mothers and children as a unit when developing policy and programming to facilitate the goal of keeping mothers and children together.

Researchers at the Centre of Excellence for Women’s Health worked with other researchers, service providers and women with lived experience to create a practical and forward looking resource designed to inspire self-reflection and action, to promote an immediate impact on current policy and practice. The tools are designed to help us continue to build on our capabilities to make mothers’ needs and voices central in our work, and to offer mother-child centred, trauma informed, culturally safe and harm reduction-oriented services and policies related to women’s use of alcohol, opioids and all other substances.

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).

Just published: 2019 edition of FASD Prevention Annotated Bibliography

Researchers associated with the Prevention Network Action Team (pNAT) of the CanFASD Research Network search the academic literature each year for articles related to prevention of fetal alcohol spectrum disorder (FASD). Articles are reviewed for relevancy, identified by topic and country, and the findings briefly summarized. This year’s Annotated Bibliography of Articles Published in 2018 was published in time for the 8th International Conference on FASD in March. A total of 58 articles were identified from 17 countries. The number of articles varies each year based on journal articles published in English about ongoing or new research on FASD prevention research. Countries with highest number of published articles in 2018 were USA (26 articles), Canada (9 articles), the UK and Ireland (6 articles), and Australia and South Africa (5 articles each). 

Findings are organized using a four-level prevention framework used by the pNAT to describe the wide range of work that comprises FASD prevention (see panel at left for more information). This year 15 articles pertained to Influences on women’s drinking;  12 articles pertained to Level 2, discussion of alcohol use with women and their support networks; and, 11 articles pertained to Level 3, specialized and holistic support of pregnant women. Articles pertaining to Level 1 and Prevalence of alcohol use in pregnancy were also well represented. Some articles are assigned to more than one category.

Figure 1: Four Levels of FASD Prevention

The annual literature search is intended to update those involved in FASD prevention in Canada, to inform their practice and policy work with current evidence. The members of the pNAT also have the opportunity to discuss the implications for their work of the findings of selected articles, in monthly web meetings.

Find earlier Annotated Bibliographies below and on the CanFASD Prevention page under “Bibliographies”.

Linking cannabis use with alcohol and tobacco

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

New book published: Mothers, Addiction and Recovery

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

Housing is key component to women’s recovery

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.

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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.

 

Heavy drinking among women: Normalising, moralising and the facts

The 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.
• 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.

 

 

WHO Europe: Prevention of harm caused by alcohol exposure in pregnancy

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.

In 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

Holistic and specialized support for pregnant women: Level 3 prevention

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. We’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. The 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.