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.
In our work on FASD prevention, reaching women on the topic of the effects of alcohol use before they are pregnant is a much needed component. Yet when offering a continuum of perinatal and reproductive care, our health care systems usually do not make preconception health a priority. It is indeed a challenge to promote critical thinking about alcohol use in pregnancy when women a) are not yet actively planning a pregnancy, b) are unaware, misinformed or unconcerned about of the effects of alcohol, or c) are acutely aware of the stigma associated with drinking alcohol in pregnancy and resistant to hearing the message.
In a recent article for the UK journal, International Journal of Birth and Parent Education, we described what is known about empowering and effective preconception health interventions, to catalyse and support the work of health care practitioners working with women of childbearing years.
We entitled the article “Beyond Screening” as it is important to enter discussions about alcohol use in pregnancy as conversations that reduce stigma and support critical thinking about alcohol use before, during, and after pregnancy.
In a section of the article entitled “Issues and Actions Needed” we offered 8 key considerations when offering preconception education and support on substance use issues:
moving beyond screening – Asking about what women know about effects of substance use in pregnancy and what their plans are, may be more engaging and helpful to open conversations, rather than starting with formal screening questions
reducing stigma – By naming how stigma and fears of judgement may be a barrier, health care providers can build an open relationship with women that facilitates safety and empowerment
involving women – In the context of substance use by women overall, and in pregnancy, where judgement, bias, discrimination, misinformation and stigma are rampant, it is particularly important to involve women respectfully and collaboratively in defining what works for them
involving men/partners– Involving partners in preconception and prenatal care, messaging, and support can be an important strategy for reducing the weight of pregnancy planning for women, and for improving overall health.
using technology – Web-based support on substance use issues is increasingly available to extend the reach and engagement by the public in early and accessible assistance. Sharing where such information is available, supports the seeking of assistance in an anonymous and self determining way
building on practitioner wisdom and relationships – Motivational Interviewing and other evidence informed practices are already being used by many practitioners for guiding conversations on substance use that are trauma informed, harm reduction oriented and strengths based. These approaches are highly relevant in conversations about substance use before, during and following pregnancy, and can be best ‘heard’ in conversations with trusted providers.
multi-tasking – The benefits and reach of dual focus preconception interventions (that involve discussion of substance use with other health issues) are important. Integrating discussion of how alcohol may be a factor linked with nutrition, mental wellness, prevention of intimate partner violence and/or housing can be helpful, and respectful of women’s interests.
embedding preconception conversations in multiple systems of care – It is vital that preconception care be well integrated in health, social, and community care, with many types of practitioners all playing a role.
We are appreciative of being asked to revisit what we know about preconception interventions, and see it as important for everyone to ask of their communities and countries:
Who is doing preconception interventions on alcohol and other substance use?
In what additional contexts can preconception health and substance use issues be raised?
How can we promote gender and other forms of equity as we are doing preconception interventions on substance use?
What does each practitioner need to support action on this level of FASD prevention?
Harm reduction and health promotion for women and their partners before conception are key to FASD prevention . 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 . Such education and support can contribute greatly to optimizing health and preventing FASD .
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.
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 . 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 . 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  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 . 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.
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
This study from the University of Cardiff in Wales has confirmed what most women’s health advocates know – that judging pregnant women for behaviours that may negatively affect fetal and child health, did not cause them to stop, but instead caused them avoid public and professional scrutiny, and to use in private. Women felt judged by healthcare professionals for their smoking and poverty, which made interactions with health care providers awkward. (See journal article on the study here.)
In the research 10 low-income, pregnant women in Wales were asked to “tell their stories” including how pregnancy affects their everyday life. Although smoking was discussed extensively by the women, interviewers did not raise the topic during the interviews. As part of their stories, women described their smoking behaviours, and reactions from the public, family, friends, and health care providers.
This study underscores what we know about substance use prevention in general – shame and stigma are not solutions to helping people change use, and specifically that the judgement of health professionals is tied to not accessing the support that is needed and deserved. In that way, the professionals become part of the problem instead of the solution. Evidence has established that using non-judgmental approaches are key to supporting behaviour change. These approaches emphasise harm reduction and employ collaborative and empathic conversations that respect individuals’ self determination and understand the underlying issues of substance use problems. Further to collaborative conversations, it is critical to understand substance use, and challenges to change substance use, as related to the burdens of violence and poverty faced by women – this forces us to move beyond a focus on individual behaviour and instead to action for social justice on these conditions of women’s lives.
The pNAT has written extensively about the importance of non-judgmental Level 2 discussions with women and their partners about alcohol, other substance use and the determinants of health that affect use. Included here are some resources that can help practitioners to engage in those discussions with women in a way that builds connection and relationship and supports movement toward positive change in alcohol and tobacco use, and related health and social concerns. As well, practitioners can connect to local pregnancy and addictions support programs to learn what community action to address stigma and promote social justice is underway.
Weinberger, A. H., Platt, J., Esan, H., Galea, S., Erlich, D., & Goodwin, R. D. (2017). Cigarette Smoking is Associated with Increased Risk of Substance Use Disorder Relapse: A Nationally Representative, Prospective Longitudinal Investigation. The Journal of clinical psychiatry, 78(2), e152-e160.
With most everyone having a smartphone these days, people are using apps to support their health. There are a few apps directed to pregnant women about their substance use and mental health. Some recent efforts developed together by researchers and health providers show how these apps can be used to offer focused information and support to pregnant women.
A perinatal mental health research project in Alberta, The Hope Project, is exploring how e-technology can be used to support pregnant women with mental health concerns. Dr. Dawn Kingston and her team at the University of Calgary developed an app for screening and treating pregnant women experiencing anxiety and depression. It provides information, support, and help to women in the research study whenever they need it. The project will also look at how this intervention affects post-partum depression and the health of their children.
SmartMom Canada, was developed as part of a study from the University of British Columbia. Through text messaging, Optimal Birth BC provides women in Northern BC with prenatal education endorsed by the Society of Obstetricians and Gynaecologists of Canada (SOGC). Many of these women live in rural areas and may have limited access to prenatal care. Women who enroll in the study complete a confidential survey and then receive personalized text messages that include pregnancy tips, info on health topics, and available resources in their own community.
Women outside of these studies may find it challenging to find similar apps. Popular pregnancy apps do not offer much info or ideas for resources for women with mental health or substance use issues. One that has been positively evaluated is Text4baby in the U.S. The sponsors partner with national, state, and private organizations and offer local resource information in some states. Also available to Spanish speakers, an evaluation of the app can be found here.
Most apps available on smartphones are directed toward the general population and seek a large user base. Mental health apps and substance use apps that might support prevention, are not designed specifically for women, pregnant or not. And most pregnancy apps focus on fetal growth and “kick counters”, the woman’s weight and blood pressure, and checklists to get ready for a child.
So, while there is an app for everything, they may not an app for everyone. However, healthcare technology is growing at a fast pace, so hopefully we will see more apps in future that can expand FASD prevention efforts.
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.
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
With marketing of alcohol and nicotine delivery products to youth, legalization of cannabis, and the crisis in prescription pain medication use, there are new opportunities to have conversations with youth about substance use and pregnancy, with the aim of reducing the harms and improving their overall health.
What do we know about youth understanding of substance use and pregnancy?
Existing research and data on youth behaviour provide a window.
One U.S. study showed a relationship between pregnancy and prior substance use among adolescents, and among younger adolescents in particular.
59% of pregnant teens and 35% of nonpregnant teens reported having used substances in the previous 12 months.
Some substance use continued in pregnancy particularly among younger pregnant adolescents ages 12-14. (1)
The McCreary Centre Society conducts an adolescent health survey in BC every 5 years. The 2018 evaluation is underway, but findings from 2013 indicated a number of factors related to youth substance use and pregnancy.
Those at higher risk for harmful alcohol use include:
Youth in rural areas
Youth who were born in Canada
Youth who were employed
Youth living in poverty
Youth experiencing abuse or violence
Sexual minority youth
Peer relationships have risks in terms of starting drinking earlier and binge drinking particularly when friend groups are large.
Those at greater risk of being involved in a pregnancy include:
Youth who first had sex before their 14th birthday
Youth in rural areas
Youth who had been in government care. Among these youth, girls were more likely than boys to be have been involved in a pregnancy
Youth who had been physically abused
Youth who had been sexually abused. Among these youth, males who were more likely to have been involved in a pregnancy.
The Ontario Student Drug Use and Health Survey (OSDUHS) from 2017 shows that:
17% of youth have participated in binge drinking and 16% cannot remember what happened during that time
Boys are more likely to use e-cigarettes and all forms of tobacco, over-the-counter cold/cough medications, energy drinks, cannabis, and psychedelics
Girls are more likely to use prescription opioids for pain relief and tranquilizers medically
How do we approach building awareness and prevention?
Opening “Doorways to Conversation” about substance use and pregnancy allows for brief interventions and support for youth as well as women and girls. Many providers think that they need to have appropriately tested screening tools along with the knowledge, skills and confidence to conduct them. As one United Nations study found, less than 30% of health providers routinely screened youth for substance use for these reasons.(2)
Trauma-informed, culturally relevant, and gender-specific relational approaches build trusting relationships that can support youth who may be dealing with more complex issues like violence and abuse, gender identity, or the foster care system.
Promising Approaches for Reaching Youth on Substance Use and Pregnancy
Here are some current promising approaches to improving youth understanding of substance use and pregnancy in Canada.
Projects like “Let’s Get Real About Drinking Alcohol” are trainings for youth focusing on the interconnection of substance use, safe sex, birth control, and drinking during pregnancy. You can view a webcast about the project here.
This handout offers conversation starters on substance use for group facilitators. Girls Action Foundation “Take Care” program provides a curriculum and resources for facilitators of girls’ groups to promote critical thinking about healthy living including substance use and sexuality.
Christopher P. Salas-Wright, Michael G. Vaughn, Jenny Ugalde, Jelena Todic. Substance Use and Teen Pregnancy in the United States: Evidence from the NSDUH 2002–2012. Addictive Behaviors, 2015; DOI: 10.1016/j.addbeh.2015.01.039
Chakravarthy, B., Shah, S., & Lotfipour, S. (2013). Adolescent drug abuse – Awareness & prevention. The Indian Journal of Medical Research, 137(6), 1021–1023.
Research has shown that everyone has a role to play in preventing FASD and that positive messaging is most effective for promoting awareness and discussion of alcohol use during pregnancy. Understanding positive messaging can help avoid the unintended negative consequences we have seen from previous efforts. Prevention-positive principles include:
Using non-exploitative imagery. Prevention campaigns are replacing lone naked-belly images with those that emphasize the mother-child dyad within a supportive network.
Respectful messaging that encourages women to access help if they need it rather than fear-based or blaming messaging like “if you loved your baby, you wouldn’t drink.”
Linking to where information and help is available.
Not describing FASD as “100% preventable” as this may lead women to think that the system of care won’t welcome them if they have already consumed alcohol in pregnancy.
Here are some recent examples of prevention-positive efforts from across Canada.
The Yukon FASD Interagency Advisory Committee is taking a prevention-positive approach with their “Alcohol-free is supportive” campaign. It consists of posters in English and French, ads in the local theatres, online ads, and a radio ad as featured on CKRW. Below is an example of one poster with plans for others in the coming months. Partners in this project are the Yukon Government, Fetal Alcohol Syndrome Society of the Yukon (FASSY), and Child Development Centre.
Women can sign up to do a “Dry 9” and receive a t-shirt and emails of support during their pregnancy. The Dry 9 movement encourages others to support women who decide not to drink any alcohol during their pregnancy. Short videos on topics such as the “Persistent Friend”, “Co-Parent to Be”, and the “Previous Generation” can be shared with others. The Alberta Gaming and Liquor Commission launched the Dry 9 movement last December as part of DrinkSense.
Health professionals in Québec City will use printable pamphlets to have discussions with women and their partners about alcohol and pregnancy. Besides information on alcohol and FASD, the pamphlets, published with the help of Public Heath Agency of Canada, describe fetal development, and resources and support. Link to brochures and posters can be found on the Dispensaire Diététique de Montréal site.
Having discussions about alcohol and birth control with all women of childbearing age and their partners has proven to be an effective FASD prevention strategy. This FASD ONE prevention poster aims to encourage health and social service providers to have discussions and to support a universal screening approach.
For previous posts about other prevention campaigns, see:
When you sign up for online alerts regarding new FASD research, a lot of research articles come your way. Some offer hope like the recent article on a possible future treatment for newborns diagnosed with FASD (see Common drugs reverse signs of fetal alcohol syndrome in rats). But most are headlines about newly identified risks associated with alcohol-exposed pregnancies.
From a scientific research standpoint, it’s important to fully understand effects of alcohol -exposed pregnancies. But, from a prevention point of view, does it add anything to our efforts to know one more reason drinking alcohol during pregnancy is risky? Does it lessen the stigma these women face? Would one more identified risk be the thing a woman needed to hear in order to stop drinking in her pregnancy or while trying to become pregnant?
Obviously, the full picture of effects is important, and this kind of medical and scientific research should continue. At the same itme, it would be helpful to see more headlines on what has been discovered around prevention – focusing on programs that support the mother child dyad, efforts to reduce stigma, and implementation of trauma-informed and FASD-informed practices and policies.
How about five headlines like these?
Relational treatment programs reduce risk of alcohol-exposed pregnancies and FASD
Connection to culture is key to prevention for many women
Changes in alcohol policy contribute to reduction of violence against women and incidence of alcohol-exposed pregnancies
Secure housing contributes to reduction in alcohol-exposed pregnancies
Women who can safely discuss alcohol with their health provider are more likely to stop risky drinking
In 2016, the UK Chief Medical Officer with endorsement from the Royal College of Midwives updated advice on drinking alcohol during pregnancy, stating:
“I want pregnant women to be very clear that they should avoid alcohol as a precaution. Although the risk of harm to the baby is low if they have drunk small amounts of alcohol before becoming aware of the pregnancy, there is no ‘safe’ level of alcohol to drink when you are pregnant.”
This month, the Centre for Pregnancy Culture Studies (CPCS) and others have been getting a lot of press for the claim that women are being unnecessarily frightened by this most recent advice and may be terminating pregnancies because of it (see post below for facts on this). They say that women who choose to drink at low levels during pregnancy are being stigmatized when the facts don’t support the guidelines. Further, they claim “the exclusion of women from an ordinary activity on the basis of ‘precaution’ can more properly be called sexist than benign.” (The Guardian, May 17, 2017)
That they see alcohol as a normal activity that women should have a right to, does a disservice to both feminism and to alcohol education. There is definitely here a reluctance to examine alcohol as a substance that has the potential to negatively affect health in all situations, and is a teratogen in the context of pregnancy. More, rather than less, discussion of alcohol on men’s and women’s health, and not only in relation to preconception and pregnancy would be welcome. Canada’s Low Risk Drinking Guidelines could inspire more public consideration of what we know and don’t know about alcohol.
CPCS’s comments were in tandem with a larger Policing Pregnancy conference held last week. And on points of pregnancy policing, we agree. Facts show that policing pregnancy increases stigma and pushes women to the margins so that they don’t get the help they want . Women should not be policed for their actions in pregnancy, rather they should have access to information and conversations that can support their decisions.
Preconception and prenatal health care with a caring and knowledgeable health care provider is critical to helping women have the best health and pregnancy possible. How many women have the kind of discussion of alcohol and the care they deserve?