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

Policing or Supportive? Why We Shouldn’t Test Pregnant Women for Alcohol Use

telegraph screen shot

Recent research from the UK is sparking discussion about whether routinely testing pregnant women for alcohol use would be helpful.

While the researchers are insisting that binge drinking is ‘prevalent and socially pervasive’ and stronger measures are required, others argue that biological testing is a form of policing women and one that is counteractive in long-run

Sally Peck in her article in The Telegraph says:

“But here’s why we shouldn’t test pregnant women on their alcohol consumption: policing rather than supporting pregnant women fails to prepare them for motherhood.

Instead of imposing prison-style booze tests, let’s talk more about how to help women and men navigate the early years of parenthood, and how to get help when they need it. And let’s make sure that the help we promise – or say that they should have – is actually available to them.”

Research has shown that testing women for alcohol and drug use during pregnancy fails to support women and their babies in the long-run. Women with substance misuse concerns are less likely to seek help from health care providers and avoid prenatal care. And while women in all socio-economic brackets use substances, certain groups of women are unfairly targeted and subject to more invasion of their privacy and are likely to experience adverse outcomes from testing (e.g., child protection reports, custody hearings). As well, routine testing raises ethical issues around consent (e.g., what happens if a mother says she doesn’t want to be tested? Should a health care provider do the test anyway?), women’s autonomy and self-determination, and patient-doctor confidentiality.

Read early posts on the politics and ethics of testing pregnant women for alcohol use:

What are the unintended consequences of alcohol and pregnancy warning labels?


Alcohol warning labels have been used by a number of provinces, states, and countries as a way of trying to prevent FASD by encouraging women to abstain from alcohol consumption during pregnancy.

While popular with the general public and widely promoted by many groups and organizations, their use remains controversial as there is limited evidence for their effectiveness. A scoping review published last year (Thomas et al, 2014) concluded that alcohol warning messages have the most influence on low-risk drinkers and have not been shown to change the drinking behavior of those who drink heavily or binge during pregnancy.

In a recent article published in The American Journal of Bioethics, Emily Bell, Natalie Zizzo & Eric Racine (2015) discuss ethical concerns stemming from the questionable effectiveness of alcohol and pregnancy warning labels:

There are good reasons to question the use of alcohol labels and the narrow messages they convey as methods of primary prevention for FASD. They risk perpetuating restrictive and unsupportive policies toward pregnant women with alcohol abuse issues. They may create fear and anxiety among women who drink before realizing they are pregnant, and they fail to support a comprehensive picture of FASD prevention (i.e., no information resources, no focus on the family’s, partner’s, or society’s roles). (p.19)

They comment on how the promotion of alcohol and pregnancy warning labels may be related to a belief that “doing something is better than doing nothing.” And, while it could be argued that alcohol warning labels support longer term changes in the acceptability of drinking patterns among women and the public, research has failed to demonstrate measurable changes in drinking since they were introduced.


For more on warning labels, see earlier posts:


Bell, E., Zizzo, N. and Racine, E. (2015) Caution! Warning Labels About Alcohol and Pregnancy: Unintended Consequences and Questionable Effectiveness. The American Journal of Bioethics, 15:3, 18-20, DOI:10.1080/15265161.2014.998376

Thomas, G., Gonneau, G., Poole, N., and Cook, J. (2014). The effectiveness of alcohol warning labels in the prevention of Fetal Alcohol Spectrum Disorder: A brief review. International Journal of Alcohol and Drug Research, 3(1):91-103. doi: 10.7895/ijadr.v3i1.[Open Access]


Alberta Harm Reduction Conference: Focus on pregnancy, substance use and policy


The 13th Annual Alberta Harm Reduction Conference will be held June 2-3, 2015 in Edmonton, Alberta. This year’s conference will feature a one-day session on June 1st focusing on pregnancy, drug use, and policy.

This year, the conference is being co-hosted by Streetworks and AAWEAR (Alberta Addicts who Educate and Advocate Responsibly), the provincial coalition of people who use drugs. Attendees will include frontline workers, people (who admit to) using substances, professionals, researchers, policy makers, students and folks who are interested in the issues surrounding substance use and sex work. The presenters represent those involved in research, policy and practice.

The conference will address HIV and Hepatitis C, overdose prevention, supervised consumption, criminalization/legalization of substances, sex work laws, racism and incarceration, access to heroin and methadone, pregnancy and drug use, education of our youth, marijuana legalization in the US, managed alcohol programs and many others.

Harm reduction is an important approach to addressing alcohol use during pregnancy for women with addiction concerns and who are at highest risk of having a child born with FASD.

Learn more about the conference here.

FASD Issue Papers from the Canada FASD Research Network provide a quick overview of recent research


The Canada FASD Research Network has developed a series of “issue papers” that provide a 2-3 page overview of a range of issues related to FASD based on the latest research.

Some of the prevention-related topics include:

Other topics related to FASD more generally include:

These issue papers can be a great way to catch up on recent research or to get a quick overview of an area of work you’re not as familiar with. All the issue papers can be downloaded from the Canada FASD Research Network website.


Everyday Struggles, Everyday Strengths: report from Young Women United

Capturing the voices of women living though pregnancy and addiction


I blogged earlier this year about an organization in New Mexico called Young Women United (see the post: Young Women United: Campaign to Increase Access to Care and Treatment for Pregnant Women with Addictions, February 18, 2014).

The organization has released a new report called “Everyday Struggles, Everyday Strengths: Capturing the voices of women living though pregnancy and addiction.

Some of the key findings from their work with women include:

1. Most women described intense feelings of fear as guiding their decisions.

  • They were fearful their kids would not be healthy and that they would be at fault.
  • They were scared of being reported to child welfare authorities and losing custody of their baby as well as other children.
  • While some women disclosed their substance use and others hid their substance use, almost all women were scared to talk about their substance use due to risk to their families.

2. The majority of women reported judgement and discrimination while trying to access prenatal care.

  • Some women reported that their health care providers allowed their own opinions on addiction to impact the care they provided, regardless of whether those decisions were sound or legal.
  • Many women said they were not treated respectfully or kindly.
  • Several women reported being threatened with inaccurate information (e.g., “You know they’re going to take those kids away from you?”)

3. Women reported not being able to access the care and support they needed.

  • It was difficult to access prenatal care that incorporated addiction treatment or addiction treatment that considered pregnancy.
  • For many families, treatment was only affordable when facing criminal charges.
  • For women who are mothers, residential treatment was usually inaccessible because they could not take their children with them and/or they did not have a safe place for their children to stay in their absence.

This report seems especially timely given the announcement a couple of weeks ago when the governor of Tennessee announced a new law to authorize the arrest and incarceration of women who use drugs while pregnant. (See the coverage in the Huffington Post here and the Washington Post coverage here).

While the Tennessee bill is the first state to actually criminalize drug use among pregnant women, other states have been prosecuting pregnant women under different kinds of laws for years. The criminalization and prosecution of pregnant women who use alcohol and drugs has been critiqued by hundreds of health and other organizations as poor public policy and has not been shown to lead to positive outcomes.

For more on this issue, see earlier posts:


European FASD Alliance Position Paper: Mothers who drank during pregnancy should not be punished


Screeshot - Telegraph_Feb 2 2014

Over the past couple of months, there has been media attention about a new legal test case going before the Court of Appeals in the United Kingdom. This case has raised concerns and discussion in Europe (and elsewhere) about punishing women who drink alcohol during pregnancy.

The case in the UK is arguing that a six-year-old girl who suffered brain damage due to alcohol exposure in the womb is the victim of a crime (grievous bodily harm). While this claim was initially overturned in December 2011, an appeal is going forward. If successful, women who drank during pregnancy could be convicted of a criminal act. Interesting, this is occurring even while current UK national guidelines on alcohol use during pregnancy state: “Expectant mothers should avoid alcohol – but if they do choose to drink, they should limit their consumption to one or two units a week.”

The European FASD Alliance released a position statement last week called “Drinking during pregnancy-who is responsible?

“The EUFASD Alliance does not agree that mothers who drank during pregnancy should be punished. We recognize that there are many reasons that women drink, for example not knowing that they are pregnant, or due to bad advice from their health care advisors or the press. We recognize that social pressures play a great role in encouraging women to drink.”

The position statement has been cosigned by a number of other organizations. See the position paper here on the European FASD Alliance website.

For more on punishing or criminalizing alcohol use during pregnancy, see early posts:

Free Public Forum: Challenging Drug Prohibition & the Regulation of Reproduction and Mothering


Susan Boyd from the Centre for the Study of Gender, Social Inequalities and Mental Health at Simon Fraser University is hosting a critical dialogue about the intersections of drug prohibition, women, addiction, and the regulation of reproduction and mothering with some of the leaders in the field.

The public forum will be held Saturday, May 17th, 2014 from 9:30am – 5pm at SFU Harbour Centre in Vancouver, BC. View the flyer here. The event is free but registration is required.

Speakers include several members of the Canada FASD Research Network, including Marliss Taylor from the Streetworks program in Edmonton and Lenora Marcellus from the University of Victoria.

State Policies on Substance Abuse During Pregnancy


The Guttmacher Institute in the United States works to advance sexual and reproductive health and rights through research, policy analysis and public education.

The two-page Substance Abuse During Pregnancy is part of their “State Policies in Brief” series and tackles the subject of how women’s substance abuse during pregnancy is dealt with at a policy level. While no state specifically criminalizes drug use during pregnancy, many prosecutors use other criminal laws to address prenatal substance use.

“Several states have expanded their civil child-welfare requirements to include prenatal substance abuse, so that prenatal drug exposure can provide grounds for terminating parental rights because of child abuse or neglect. Further, some states, under the rubric of protecting the fetus, authorize civil commitment (such as forced admission to an inpatient treatment program) of pregnant women who use drugs; these policies sometimes also apply to alcohol use or other behaviors.

A number of states require health care professionals to report or test for prenatal drug exposure, which can be used as evidence in child-welfare proceedings. And in order to receive federal child abuse prevention funds, states must require health care providers to notify child protective services when the provider cares for an infant affected by illegal substance abuse. Finally, a number of states have placed a priority on making drug treatment more readily available to pregnant women, which is bolstered by federal funds that require pregnant women receive priority access to programs.”

The summary includes a checklist of which states consider substance abuse during pregnancy as child abuse or grounds for civil commitment, which states require reporting or testing when substance misuse is suspected, and which states have specific programs for pregnant women who use substances and give pregnant women priority access to general programs.

For more on the criminalization of prenatal substance use and legal issues related to FASD prevention, see earlier posts:

Legal Measures to Prevent Fetal Alcohol Spectrum Disorder

Video on Legal Issues and FASD Prevention now available

Legal Measures to Prevent FASD

In September 2013, the Institute of Health Economics (IHE) held the first-ever Consensus Development Conference on Legal Issues of FASD in Edmonton, Alberta.

The three-day conference examined issues such as:

  • What are the implications of FASD for the legal system?
  • Is there a need for enhanced efforts to identify people with FASD and how can these efforts be achieved?
  • How can the criminal justice system respond more effectively to those with FASD?
  • How can family courts and the family/child welfare legal system address the specific needs of people with FASD?
  • What are the best practices for guardianship, trusteeship and social support in a legal context?
  • What legal measures are there in different jurisdictions to contribute to the prevention of FASD and what are the ethical and economic implications of these measures?

Nancy Poole, Director of Research and Knowledge Translation at the British Columbia Centre of Excellence for Women’s Health and FASD Prevention Team Lead with the Canada FASD Research Network, gave a fantastic 30 minute presentation called “Legal measures to contribute to prevention of FASD, effectiveness and ethical issues. Some of the issues that she addresses are:

  • Alcohol and pregnancy warning labels
  • Measures to ban selling or serving alcohol to pregnant women
  • Interventions targeted at pregnant women with addictions
  • Measures related to contraception, and
  • Compulsory testing of pregnant women for alcohol

Some of the issues discussed following the presentation included the importance of alcohol brief interventions by health care providers, involving men in FASD prevention, subsidizing long-acting contraception, targeted vs. universal interventions, the relationship between women’s empowerment and successful FASD prevention, and the broader context of alcohol consumption in society.


Some of the themes from this presentation can be found in the Consensus Statement developed following the conference.

The 2013 Consensus Statement on Legal Issues of Fetal Alcohol Spectrum Disorder (FASD) was produced by a distinguished jury led by the Honourable Ian Binnie, former Justice of the Supreme Court of Canada, and includes a range of recommendations calling for changes to the way people with FASD are dealt with by the legal system in Canada. Recommendations related to FASD prevention (p. 35) included:

59. Develop a comprehensive FASD prevention strategy for Canada.

60. Develop gender-specific programs and create opportunities for women and men to discuss with their health care provider relationship issues, child care, and alcohol consumption.

61. Prevention programs should focus on those areas in which positive effects have been demonstrated. In particular, it may be worthwhile to examine interventions involving the mother-child unit. Such approaches might help reduce the likelihood of subsequent children with FASD after a child is found to suffer from an intellectual impairment or neurological disorder such as FASD.

62. Develop evidence-based mandatory training programs for front-line workers on how to talk to women in a secure, non-threatening fashion about the underlying causes of alcohol consumption

Videos from the entire conference are available for viewing on the IHE website here.