The Legacy of the Co-Creating Evidence Project

Click here to listen to the blog (4:53).

The Co-Creating Evidence (CCE) Project has been a first-of-its-kind-in-Canada national evaluation involving 8 different programs serving women at high risk of having an infant with FASD or prenatal substance exposure.

The goals have been to:

• Bring together many of Canada’s holistic FASD prevention programs to share promising approaches and practices;
• Evaluate the effectiveness of multi-service programs serving women with substance use and complex issues;
• Identify characteristics that make these programs successful.

Representatives of the eight programs and researchers from Note Bene Consulting Group and the Centre of Excellence for Women’s Health have collaborated since 2017 to achieve the following:

The 8 programs involved in the CCE Project.

• 256 program participant interviews, 108 staff interviews, and 60 interviews with community partners of the services
• A detailed report of all study findings (96 pages) for all audiences
• 12 info sheets on key components found to be helpful, to support the work of service providers
• 4 journal articles, to bring awareness of the findings to researchers and health system planners
• Webinars to share what was learned
• A booklet on culturally grounded approaches within wraparound programs for all audiences (24 pages)
• A digital handbook highlighting key components of wraparound programming found to be helpful, for service providers and peer mentors wishing to start a wraparound program or enhance the work they already offering

Wraparound services offered by the 8 programs participating in the Co-Creating Evidence project

The 8 programs were guided by a similar set of theoretical approaches, including being trauma-informed, relationship-based, women-centred, culturally-grounded, and harm-reducing.

The range of services offered by wraparound services is key for women in finding what works for them, and in having the opportunity to choose the order and pace of services they will use.

The study has demonstrated that pregnant and early parenting women experiencing problematic substance use and other complex issues benefit from programs that include: Wraparound services – Knowledgeable and empathetic program staff – Indigenous (re)connection – Opportunities for community/peer support.

Further, the following elements are important characteristics that contributed to the programs’ success: Well conceptualized, evidence-based approaches – Strong partnership relationships – Flexible, multi-dimensional models – Keeping clients engaged over time.

The Digital Handbook on Wraparound Programs is a key legacy of the CCE Project. The handbook was developed with multiple audiences in mind, including program planners, managers and staff, service partners from a variety of health and social sectors, funders, researchers, community members, and families affected by perinatal substance use.

The Handbook is a remarkable, accessible collection of resources about:

• Relationship-based practice
• Trauma- informed approaches
• Culturally safe care
• Harm reduction approaches
• FASD informed approaches
• Indigenous cultural programming

• Attachment focused practice
• Transitioning from wraparound services
• Building partnerships
• Cross sectoral work
• Wraparound programs as good investments
• Data collection approaches and more

Opening page of Topic 14 in the digital handbook

The Handbook supports one of the implications arising from the study:

“Ongoing learning opportunities, focusing on integrated, culturally grounded, trauma informed, relational practice, are important to practitioners in all fields and need to be actively supported.”

See the Executive Summary of the Co-Creating Evidence Evaluation Report for all the implications identified: 6 directed to practitioners, 5 for health system planners, and 6 government policy makers and funders.

Next month’s blog will feature, A Mustard Seed of Hope, a booklet created through the CCE Project about culturally grounded approaches within wraparound care for Indigenous pregnant and parenting women dealing with substance use and trauma.

Funding for this project was received from the Public Health Agency of Canada.  The views expressed do not necessarily represent the views of the Public Health Agency of Canada.

Preconception Resources: Increasing Awareness about Alcohol and Pregnancy

Click here to listen to the blog (3:18).

Preconception care is part of a continuum of support that promotes health during the reproductive years: for young girls and women who may be drinking alcohol without using effective contraception, those who are planning a pregnancy, and people in the interconception periods. Preconception care includes health promotion, education and counselling support that may have a focus on: protection (i.e., folic acid supplementation), avoiding harms (i.e., of alcohol use during pregnancy), and/or managing conditions (i.e., diabetes).

Discussing substance use in the preconception period can encourage reduction in alcohol and other substance use before and during pregnancy.  For example, pre-pregnancy alcohol use is a predictor of alcohol use during pregnancy and smoking fewer cigarettes pre pregnancy is a predictor of quitting smoking during pregnancy. Despite the importance of reaching women in the preconception period, efforts to do so have not always been prioritized by our health systems or in training to health and social service providers.

Two booklets designed to promote preconception care

In response to this gap in resources for people planning a pregnancy, the Centre of Excellence for Women’s Health and Canada FASD Research Network recently developed Thinking About Pregnancy: A Booklet to Reflect on Alcohol Use Before You are Pregnant. The booklet recognizes women’s agency and interest in learning more about supporting a healthy pregnancy. As such, we translated what we know as researchers into an accessible booklet for women that they can use independently or walk through with their partner(s) and healthcare providers when thinking about or planning a pregnancy.

Included in the booklet is information about standard drink sizes, why thinking about alcohol before you are pregnant is important, mocktail recipes and activities that help women reflect on what they like or dislike about drinking, what alternatives to alcohol use may be in their ‘toolbox’ and who is and will be by their side as they make change.

Project CHOICES in Manitoba offers another booklet that aligns with and complements Thinking About Pregnancy. While Thinking About Pregnancy is geared towards people who are planning a pregnancy, Project Choices: Alcohol and Sex Deserves a Discussion (available in French here) is geared towards youth and young adults who drink alcohol, are having sex, and want more information about alcohol use and birth control.

The booklet contains information on alcohol, contraception, and consent, and includes a number of self-reflection, goal setting and mindfulness activities that can help decrease alcohol use and/or increase contraception use and safe sex. Although the booklet can be used as a stand-alone resource, counsellors in the Project CHOICES program also use this booklet to educate participants about alcohol use, birth control, FASD, and support participants towards healthy goal-setting.

These booklets are designed to be accessible for girls, women and gender diverse individuals in reproductive years. Turning more attention to preconception care offers an opportunity to promote and empower health and wellbeing, while simultaneously contributing to the prevention of FASD.

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.

Staying Principled

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

In 2009 a group of women gathered in Victoria BC Canada to discuss how we would approach the development of a network on FASD prevention. We were researchers, policy advocates, service providers, community activists and those with Indigenous wisdom – all with a commitment to seeing and acting on how social determinants affect women’s health and substance use, and the ability for them influence the conditions of their lives.

Out of our discussion emerged a consensus on 10 fundamental components or principles for approaching FASD prevention from a women’s health determinants perspective. Now, in 2022, we have updated that consensus statement, so that those interested in FASD prevention are directed to new evidence and resources. The update is a testament to the soundness of the original principles and to the ever-growing expertise of the network participants and international partners. We hope this will empower those working on FASD prevention to continue to use and build upon this principle-based approach.

The principles foundational to approaching FASD prevention are:

Respectful – Grounding prevention initiatives in respectful relationships is vital to reduce stigma and discrimination.

Relational – It can be a transformative experience for women who use substances to experience care that aligns with their needs, views them as a whole person, and offers respect, understanding, and authentic collaboration.

Self-Determining – Health care and other support systems can facilitate self-determined care by supporting women’s autonomy, decision making, control of resources, and including exercise of their reproductive rights.

Women+ Centred – Women+ centered care moves beyond a fetus/child-centered approach, and focuses on fostering safety and empowerment when providing support to women and gender diverse individuals who are pregnant or parenting.

Harm Reduction Oriented – A harm reduction oriented approach focuses on safer substance use but also on reducing broader harms, including retaining or regaining custody of children, access to adequate and stable housing, and the challenges of poverty, food insecurity, and intimate partner violence.

Trauma- and Violence-Informed – Trauma- and violence-informed services integrate awareness of the impacts of trauma on health into all aspects of service delivery including wellness support and prevention of secondary trauma.

Health Promoting – Holistic, health promoting responses to the complex and interconnected influences on women’s health and substance use are vital to FASD prevention.

Culturally Safe – Respect for individuals’ values, worldviews, and preferences in any service encounter is important, as is respect for and accommodation of a woman’s desire for culturally-specific healing.

Supportive of Mothering – FASD prevention efforts must recognize women’s desire to be good mothers and the importance of supporting women’s choices and roles as mothers.

Uses a FASD-informed and Disability Lens – Uses strengths-based responses, makes person-centered accommodations, and ensures equity of access to health and social services.

We hope you will find the Consensus Statement with these principles and supporting sources – journal articles, reports and infographics – an inspiration for action.

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. 

FASD Prevention: An Annotated Bibliography of Articles Published in 2021

This year’s Annotated Bibliography of Articles Published in 2021 was just released and includes 99 articles from 21 countries.

Researchers associated with the Prevention Network Action Team (pNAT) of the Canada FASD Research Network search the academic literature for articles related to alcohol use in pregnancy and Fetal Alcohol Spectrum Disorder (FASD) prevention. Articles are reviewed for relevancy, identified by topic and country, and the findings are summarized.

Countries with the highest number of articles published were the US (36 articles), Canada (17 articles), and the UK (13 articles). The findings were organized using a four-part prevention model used by the pNAT to describe the wide range of work that comprises FASD prevention. This year, 35 articles described the prevalence, influences, and factors associated with alcohol use in pregnancy, nine articles described Level 1 prevention efforts, 26 articles described Level 2 prevention efforts, 7 articles described Level 3 prevention efforts, 8 articles described Level 4 prevention articles, and 17 articles described stigma, ethical issues, and systemic approaches.

In this collection of articles can be seen an increase in attention to women’s views and experiences. For example, a systematic review of qualitative research exploring the barriers and facilitators that influence alcohol reduction, abstention, and use in pregnancy found that social norms and relationships, stigma, trauma and other stressors, alcohol information and messaging and access to trusted and equitable care and resources greatly impacted women’s alcohol use and that structural and systemic factors related to alcohol use were widely underexplored. Another article explored how women make decisions about alcohol use given the conflict information, controversy, and stigma associated with light and moderate prenatal alcohol consumption. The authors found that women’s decisions were influenced by the consistency of messaging they received, their social position relative to the source of information, and the strength of the relationship to the person providing information.

The annual literature search is intended to update those involved in FASD prevention in Canada (and beyond), so that their practice and policy work may be informed by current evidence. The members of the pNAT also have the opportunity in monthly web meetings to discuss the implications of the findings for their work. You can access previous annotated bibliographies from CanFASD’s prevention page or by clicking on the “Maternal Health & Substance Use” topic on the CEWH publications page.

Click here to read FASD Prevention: An Annotated Bibliography of Articles Published in 2021.

Click here to read the Executive Summary.

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

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

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

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

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

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

Source: Page 42, Mothering and Opioids Toolkit

Accessing Research to Inform our Practice and Policy

Our annual annotated list of research articles on FASD prevention is now available!

As in past years, we searched academic databases for articles about FASD prevention published in English over the past calendar year (in this case between January and December 2020). We organized the articles using the four-level prevention framework, so that those involved in FASD prevention can easily find and consider how to integrate current evidence relevant to their practice and policy work. 

This year, one hundred and three (n =103) articles were included, coming from 19 countries/regions.

• 37 articles explored the prevalence of, and influences and factors associated with, alcohol use during pregnancy. Some factors influencing alcohol use in pregnancy described in these articles included depression, partners’ alcohol use, awareness of alcohol harms, awareness of pregnancy status, adverse childhood experiences, availability of support networks, concurrent tobacco smoking, and density of alcohol establishments.
• 3 articles only focussed on awareness raising (Level 1).
• 33 articles described aspects of brief intervention, education and support with women in childbearing years and their support networks (Level 2). Mixed results are still seen for brief interventions, but for some subgroups of women and dual interventions (alcohol + contraception) benefits were found.
• 12 articles explored specialized, holistic support of pregnant women with alcohol and other health and social problems (Level 3), showing the importance of access to these programs and the need for collaboration in their delivery.
• 7 articles described postpartum treatment and support approaches for new mothers and their children (Level 4), and promising approaches were described that included trauma informed and culturally grounded parenting programs.
• 14 articles addressed overarching issues such as the impact of stigma, ethical issues and needed systemic approaches.

We encourage all those interested in FASD prevention to check out the articles for the area of FASD where they work, and in other areas of interest. We look forward to discussing key articles in the Prevention Network Action Team (pNAT) monthly web meetings as well. 

• We have added for the first time this year, an executive summary (https://bccewh.bc.ca/wp-content/uploads/2021/05/FASD-Annotated-Bibliography-2020-Executive-Summary.pdf)
• The full annotated bibliography is downloadable from  https://canfasd.ca/topics/prevention/ or http://bccewh.bc.ca/category/post/maternal-health-and-substance-use/

The Remarkable Findings of the Co-Creating Evidence Evaluation Study

Preventing Fetal Alcohol Spectrum Disorder (FASD) requires a range of efforts from general awareness to targeted prevention and treatment services. In the Canadian Four-Part FASD Prevention Model, Level 3 and 4 programs provide low barrier holistic services for pregnant or parenting women who face substance use and a range of other health and social burdens and challenges.

Over a four-year period, the Co-Creating Evidence (CCE) evaluation study has involved eight different community-based Level 3 & 4 programs that support women through the provision of holistic, wraparound services, and in doing so, see FASD prevention as part of their mandate. These programs are guided by theoretical approaches such as being trauma-informed, relationship-based, women-centred, culturally grounded and harm reducing. The evaluation team has been led by the Nota Bene Consulting Group and has involved researchers from the Centre of Excellence for Women’s Health and representatives of the eight programs. 

This CCE evaluative study (2017-2020) has had three main research questions:

1. What are the common elements of the diverse Level 3 programs across Canada?
2. What program components are helpful from women’s perspectives?
3. What are best measures to evidence outcomes and what outcomes are being achieved?

The answers to these questions are now available via:

• A 96-page full report on the study findings

• An 8-page executive summary

• 12 2-page info sheets on key components found helpful:
  • What is a Wraparound program for pregnant and parenting women?
  • Creating wraparound programs: Partnerships are essential
  • Wraparound programs through an Indigenous Cultural lens
  • Wraparound programs and Trauma-informed practice
  • Food security/nutrition and basic needs support through wrapround programs
  • Outreach and wraparound programs
  • Peer mentoring and wraparound programs
  • Improving Housing through wraparound programs
  • Reducing Substance use through wraparound programs
  • Mother-child connections, child welfare and wraparound programs
  • Improving Women’s and children’s wellness through wraparound programs
  • Co-creating Evidence study – Frequently Asked Questions

• 3 published journal articles:
  • On program structure and client perspectives  2020
  • On women’s perspectives on why they seek help and their most significant changes 2019
  • On interim findings 2019

In all these documents, service providers, researchers, policy makers and women with lived/living experience will see promising approaches and outcomes that these programs provide and the women who access these programs are realizing, together with their community partners. This study makes a significant contribution to our understanding of this level of FASD prevention. It hopefully will be an inspiration to all those committed to this important work. 

Funding for this project has been received from the Public Health Agency of Canada, Fetal Alcohol Spectrum Disorder (FASD) National Strategic Project Fund. The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada.

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

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