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How to discuss alcohol use with women of childbearing age is a topic in women’s health that is getting more attention and focus. Within FASD prevention circles, we have understood that women and their partners may not know about the risks of alcohol consumption during pregnancy or may drink before they realize they are pregnant.  Thus, they benefit from discussion of what they know, what the evidence says and options for action.

Screening, Brief Intervention, and Referral (SBIR) has long been known as an approach to guide clinicians when assessing risky alcohol use. But is the SBIR model the best approach to discussing alcohol with women of childbearing age and their partners? What are the approaches currently used across Canada? How should we discuss alcohol with women and who should do it? What works best according to the evidence?

The Centre of Excellence for Women’s Health (CEWH), the Canadian Centre on Substance Use and Addiction (CCSA), and the University of British Columbia Midwifery Program have teamed up to answer these questions. The Dialogue to Action on Discussing Alcohol with Women project has three high-level objectives: to identify current approaches; to summarize and share the available evidence; and, to promote best practices.

Nancy Poole of CEWH and Audrey McFarlane of CanFASD and Lakeland Centre for FASD at the Dialogue to Action regional meeting in Edmonton.

In order to meet their first objective, project researchers are currently conducting 12 regional meetings across Canada with physicians, midwives, nurses, and service providers in, sexual health clinics, violence against women services, alcohol and drug services, and Indigenous health services.

They are learning what is already being done and sharing what is known about promising practices and existing resources that can guide discussions and referrals. Participants are suggesting resources and tools – such as webinars, guidelines, policies and programs – that will be helpful in conducting meaningful discussions and support in their communities with women who use legal substances – or soon to be legal, like cannabis.

One early emerging idea arising from this project is that “screening” may be currently placed in the wrong location in the mnemonic list of SBIR.  Starting with brief information sharing and support (the relationship first), followed by screening/referral can be more engaging, trauma-informed, collaborative and person-centred. The rearranged approach prioritizes eliciting and appreciating individual needs and perspectives.

So the list might become BISR or even BISBIRT – repeating the conversation about substance use and ideas for action after screening as well as before it.

Participants from a regional meeting in Winnipeg, MB, discuss approaches to discussing alcohol with women that are working in their communities.

This project is one of several projects addressing FASD in Canada being funded by the Public Health Agency of Canada. You can learn more about all the projects here: https://www.canada.ca/en/public-health/news/2017/05/fetal_alcohol_spectrumdisorderincanadanewprojectfunding1.html

Read more:

Conversations on alcohol: Women, their partners, and professionals – April 23, 2017

Preconception Interventions: Trending or Mainstream? – July 21, 2016

Alcohol and FASD: It’s not just about women  – June 6, 2017

 

 

3rd in Series: First-ever FASD Prevention Plenary at the 7th International Conference on FASD: PART 2

“International Research on Discussing Alcohol with Women and Their Partners, and Empowering Professionals to Have These Conversations”: Tatiana Balachova, PhD, Associate Professor, University of Oklahoma Health Sciences Center & Prevent FAS Research Group; Jocelynn Cook, Chief Scientific Officer for The Society of Obstetricians and Gynaecologists; Lisa Schölin, Consultant at WHO Regional Office for Europe – Alcohol, Illicit Drugs and Prison Health; Leana Oliver, CEO of FARR; Cheryl Tan, Health Scientist CDC

Research shows that building awareness and offering brief interventions can help women reduce alcohol-exposed pregnancies. For a variety of reasons, not all providers feel comfortable or confident in giving information or asking about alcohol use, and they may not be sure it makes a difference in preventing alcohol-exposed pregnancies. Consequently, researchers from around the world presented their findings at the 7th International FASD Conference Prevention Plenary. They discussed whether or not brief interventions work, and if they do, then which strategies work best.

Russian study picRussia – Positive Messaging Improves Knowledge and Action

Tatiana Balachova, PhD, and her research group conducted a 3-part study to develop, implement, and test a prevention program in Russia. They found that women in Russia most trusted their OB/GYN physicians, so they developed FASD educational materials and trained physicians to deliver prevention information in two face-to-face structured interventions. FASD brochures using positive messages and images improved women’s knowledge of FASD and reduced risk for alcohol-exposed pregnancies. As well, they found that women who received the intervention reduced their frequency of alcohol use – most quitting – during in pregnancy.

JOGC picCanada – Care/Service Provider Education is key

Jocelynn Cook, Chief Scientific Officer for The Society of Obstetricians and Gynaecologists of Canada (SOGC) detailed the Vision 2020 strategies: advocacy, quality of care, education, and growing stronger. These strategies underpin their goals for care providers to focus on preconception as well as pregnancy, and deliver consistent messaging. In line with these goals. Alcohol Use and Pregnancy Consensus Clinical Guidelines that were first published by the SOGC in August 2010 were updated in 2016. The guidelines highlight the value of brief interventions and will be supported in the coming year with online education and training that recognizes “red flags” and provide best practices for supporting women’s health and engagement in discussions on potentially stigmatizing topics such as alcohol use.

who-coverWorld Health Organization – Prevalence Rates Inform Strategy

Lisa Schӧlin, consultant with the World Health Organization’s European office, described the data from Europe on alcohol consumption and drinking during pregnancy. The most recent prevalence data shows that Europe has the highest consumption rate of alcohol per capita of anywhere else in the world. As well, at 25.2%, it has the highest rate of alcohol consumption during pregnancy and the highest rate of FAS (37.4 per 10,000). These data were published in a review of the evidence and case studies illustrating good practices and areas of European action called “Prevention of harm caused by alcohol exposure in pregnancy” – you can view or download here.

FARR picSouth Africa – Short Messages Can Build Awareness

Leana Oliver, CEO of Foundation for Alcohol Related Research (FARR), explained how FARR builds upon existing health services by providing prenatal support, pregnancy planning and teaching of coping strategies to women through their programmes. Their “Do you have 3 Minutes?” campaign has been successful in building awareness within communities and in supporting prevention programmes (learn more here). As well, the FARR Training Academy offers accredited trainings and continued professional development on FASD to professionals, providers and educators. Research projects and FARR publications detail what has been learned such as the benefits of motivational interviewing and the need for preconception care and planning.

CDC picU.S. – Promoting Universal Screening and Brief Intervention

Cheryl Tan, Health Scientist, Centers for Disease Control and Prevention reviewed FASD activities currently underway. Surveillance of alcohol consumption by women of reproductive age is ongoing alongside efforts by the CDC to promote universal screening and brief interventions (aSBI) of adults 18+ years. She noted the wide discrepancy between how often providers say they conduct SBI (85%) and how often patients say they receive it (25%). As well, as a partner of the Collaborative of Alcohol-free Pregnancy, the CDC is helping to change healthcare practice through high-impact projects: 1) implement interprofessional model for prevention of AEP; 2) provide evidence for aSBI to insurers in the US; and, 3) reduce stigma associated with drinking during pregnancy.

For more these topics see earlier posts:

First-ever FASD Prevention Plenary at the 7th International Conference on FASD, March 22, 2017
WHO Europe: Prevention of harm caused by alcohol exposure in pregnancy, December 22, 2016
“Supporting pregnant women who use alcohol or other drugs: A guide for primary health care professionals”, May 15, 2016
How do partners affect women’s alcohol use during pregnancy?, August 11, 2014
Empowering Conversations to Prevent Alcohol Exposed Pregnancies: Extended Learning Webinars, May 8, 2014
The Prevention Conversation Project – Free Webcast on January 21, 2015 (Alberta FASD Learning Series), December 15, 2014
Alcohol and Pregnancy campaign from Norway, December 12, 2011
FASD Prevention in Russia, February 15, 2012

FASD Annotated Bibliography, Part 2

2015-12-Life-of-Pix-free-stock-photos-city-distributors-newspapers-AlexisDoyenIt seems more attention is being brought to preconception health and its role in FASD prevention.  We have known about the value of preconception intervention for many years. The Project CHOICES Research Group described positive intervention results using Motivational Interviewing in 2003 [1]. Yet now attention to the preconception period seems to be “trending.”

Preconception intervention has been discussed all along (we were asking about it in a landmark study in the ‘90s[2]), but the recent actions like U.S. CDC recommendations and Yukon’s placement of pregnancy tests in bars are certainly highlighting preconception alcohol use and health behaviours. The current Annotated Bibliography of articles published on FASD prevention seems to bear this recent focus out:., there were a total of five articles on preconception efforts in the 2013 list; and in articles published in 2015, that number has doubled.

In the latest annotated list, Landeen et al. says that the “fetal origin of disease theory” provides the rationale for providing preconception interventions[3]. Johnson et al. describe the development and dissemination of the CHOICES model[4] and its successful adaptation in a variety of settings. Hanson et al. have written three articles that expand on the work they did adapting and implementing a CHOICES program with the Oglala Sioux Tribe in the U.S.[5-7]. Analyses by Hussein et al.[8], Mitra et al.[9] and Oza-Frank et al.[10] suggest that preconception interventions must be tailored if they are to be successful. McBride stresses the need for preconception counseling for men, as substance use during pregnancy is not solely a decision made by women or under their control [11].

Members of the pNAT are currently undertaking a review of the literature on preconception interventions and formulating recommendations for a national research agenda. They will present some of these recommendations at the research meeting in August at the University of Regina (See www.canfasd.ca for more info on this meeting).

In keeping with our understanding of multiple forms of evidence, we are interested in knowing what you are seeing and hearing about preconception interventions on alcohol. Has preconception intervention been a part of your practice for a while? Who is funded to provide it in your location? What has worked, and how has it worked, in your experience?

For further reading on preconception interventions, see earlier postings:

Alcohol and FASD: It’s not just about women, June 6, 2016
FASD Prevention needs to begin before pregnancy: Findings from the US National Survey on Family Growth, May 20, 2015
Global Trends in Unintended Pregnancy: Implications for FASD Prevention, October 13, 2014
Impact Evaluation of the Healthy, Empowered and Resilient (H.E.R.) Pregnancy Program in Edmonton, Alberta, February 7, 2014
FASD Prevention in Nova Scotia, April 25, 2013
The Sacred Journey – new resource for service providers who work with First Nations families, August 1, 2012
FASD Prevention in Russia, February 15, 2012
New book: Fetal Alcohol Spectrum Disorder: Management and Policy Perspectives of FASD, Jan 6, 2011


REFERENCES/SUGGESTED READING

  1. Reducing the risk of alcohol-exposed pregnancies: A study of a motivational intervention in community settings. Pediatrics, 2003. 111(Supplement 1): p. 1131-1135.
  2. Astley, S.J., et al., Fetal Alcohol Syndrome primary prevention through FAS Diagnosis II, A comprehensive profile of 80 birth mothers of children with FAS Alcohol and Alcoholism, 2000. 35(5): p. 509-519.
  3. Landeen, L.B., R. Bogue, and M. Schuneman, Preconception and prenatal care–useful tools for providers of women’s health. South Dakota Medicine: The Journal Of The South Dakota State Medical Association, 2015. Spec No: p. 36-43.
  4. Johnson, S.K., M.M. Velasquez, and K. von Sternberg, CHOICES: An empirically supported intervention for preventing alcohol-exposed pregnancy in community settings. Research on Social Work Practice, 2015. 25(4): p. 488-492.
  5. Hanson, J.D., K. Ingersoll, and S. Pourier, Development and implementation of choices group to reduce drinking, improve contraception, and prevent alcohol-exposed pregnancies in American Indian women. Journal of Substance Abuse Treatment, 2015.
  6. Hanson, J. and J. Jensen, Importance of Social Support in Preventing Alcohol-Exposed Pregnancies with American Indian Communities. Journal of Community Health, 2015. 40(1): p. 138-146 9p.
  7. Hanson, J.D. and S. Pourier, 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, 2015. 13(1).
  8. Hussein, N., J. Kai, and N. Qureshi, The effects of preconception interventions on improving reproductive health and pregnancy outcomes in primary care: A systematic review. The European Journal Of General Practice, 2015: p. 1-11.
  9. Mitra, M., et al., Disparities in adverse preconception risk factors between women with and without disabilities. Maternal and Child Health Journal, 2015.
  10. Oza-Frank, R., et al., Provision of specific preconception care messages and associated maternal health behaviors before and during pregnancy. American Journal of Obstetrics & Gynecology, 2015. 212(3): p. 372.e1-372.e8.
  11. McBride, N., Paternal involvement in alcohol exposure during pre-conception and pregnancy. Australian Nursing & Midwifery Journal, 2015. 22(10): p. 51-51.

man drinking with family

For over 25 years, there have been studies seeking to understand if paternal drinking affects fetal and infant health and FASD in particular. Finding that 75% of children born with FASD had fathers who were alcoholics, Abel et al. conducted a number of animal studies that described negative effects from paternal alcohol consumption but without clear or satisfactory links to humans [1]. Consequently, FASD prevention programs have primarily focused on pregnant women, where the evidence was certain, and treated paternal drinking as largely a risk factor for maternal drinking rather than a risk factor for FASD itself.

Now, with advances in epigenetic research, two recent analyses of studies are showing that paternal factors, and alcohol use, in particular, play a larger role in fetal/child health than just passing along genes. Each study analysis systematically reviewed findings about the role of paternal alcohol consumption on conception, pregnancy, and fetal and infant health. One analysis used a paternal-alcohol consumption lens, while the other used a birth-defect lens. These results provide evidence to expand prevention efforts to men, especially in the preconception period, and to continue research in the field of epigenetics and alcohol-exposed pregnancy. (To learn about epigenetics click here.)

The first review by McBride and Johnson looked at 150 research studies and distilled them down to 11 good-quality studies. The associated effects of paternal drinking fell into three themes: impact on maternal drinking, sperm health, and fetal/infant health. Two studies showed an association between low levels of paternal drinking with lowered sperm count, as well as underdeveloped sperm leading to conception problems and miscarriage. Seven studies showed an increased risk of miscarriage when men drank 10 drinks or more per week in the preconception period, and one study found an association of all cases of ventricle malformation (heart defect) with daily paternal alcohol consumption during the preconception period [2].

The second study review by Day and Savani et al. focused on birth defects and links to paternal alcohol consumption, age and environmental factors. The authors explore the evidence for how these factors impact sperm DNA and, therefore, how the developing cells of an embryo “read” and “express” genetic instructions. For example, genes that are normally “silenced” may be “activated”. Paternal alcohol consumption epigenetically impacts the “gene expression governing individual organ development” that can adversely affect fetal development, in the immediate instance and in future generations [3]. Deficiencies in brain size, heart formation, and cognitive and motor abilities (noted as being symptoms of FASD) were linked to paternal alcohol use even when there was no maternal alcohol consumption.

Both of these study analyses contend that more research is needed in order to understand the full impact of alcohol and epigenetics, and the interplay between maternal and paternal factors. Still, this latest research supports the need for health promotion policies and practices that address men’s alcohol use, not only as an influence on women’s alcohol use, and to benefit men’s health, but also for its potential adverse effect on fetal/child health.

For more on men and FASD prevention, see earlier posts:

REFERENCES/SUGGESTED READING

Abel, E., Paternal contribution to fetal alcohol syndrome. Addiction Biology, 2004. 9(2): p. 127-133. (Link here)

McBride, N. and S. Johnson, Fathers’ role in alcohol-exposed pregnancies: Systematic review of human studies. American Journal of Preventive Medicine, Article in Press.

Day, J., et al., Influence of paternal preconception exposures on their offspring: Through epigentics to phenotype. American Journal of Stem Cells, 2016. 5(1): p. 11-18.

 

Overview: Four Levels of FASD Prevention

Information Sheet: What Men Can Do To Prevent FASD

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