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.
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?
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:
What are the common elements of the diverse Level 3 programs across Canada?
What program components are helpful from women’s perspectives?
What are best measures to evidence outcomes and what outcomes are being achieved?
The answers to these questions are now available via:
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.
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
Twenty years ago, Astley, Bailey, Talbot, and Clarren (2000)  published a study that revealed how common intimate partner violence (IPV) was amongst mothers of children with FASD. The study showed the importance of thinking broadly about the risk factors and influences of FASD and demonstrated that preventing violence against women is also a preventative measure for FASD. Research efforts since Astley et al.’s study in 2000 have continued to show that IPV is an important factor to consider when supporting pregnant women who use alcohol and other substances .
This year, researchers at the Centre of Excellence for Women’s Health (CEWH) have been conducting a rapid review to understand the complex, multi-directional relationship between IPV and substance use during the COVID-19 pandemic and provide available and accessible research evidence to frontline providers . Since the implementation of stay at home orders and social distancing recommendations, use of substances and experiences of IPV have increased. Canadians have reported an 18% increase in alcohol consumption due to the stress, boredom, and lack of a regular schedule brought on by the COVID-19 pandemic. One in 10 Canadian women are concerned for their safety and calls to the Battered Women’s Support Services in Vancouver have tripled, demonstrating an increase in help seeking by women. These findings highlight the importance of understanding how public health policies and recommendations that help curb the spread of COVID-19 can be used by partners who cause harm in coercive and controlling ways.
In our efforts to prevent and reduce substance use during pregnancy, collaboration among service providers in substance use and IPV services is essential. Understanding the interconnectedness of these issues and how they are affected by pandemics and disasters can help us address them collectively. As examples, the Learning Network at the Centre for Research & Education on Violence Against Women & Children  and Calgary Women’s Emergency Shelter  have developed educational materials to help us understand how to support women who are experiencing IPV during the ongoing pandemic. As we deepen our understanding of the risk factors for FASD to include psychosocial factors such as IPV, materials like these can help us incorporate holistic support into service provisions and better support women who are experiencing violence and aggression during the COVID-19 pandemic.
Astley, S. J., Bailey, D., Talbot, C., & Clarren, S. K. (2000). Fetal alcohol syndrome (FAS) primary prevention through fas diagnosis: II. A comprehensive profile of 80 birth mothers of children with FAS. Alcohol and alcoholism (Oxford, Oxfordshire), 35(5), 509–519. https://doi.org/10.1093/alcalc/35.5.509
FASD Awareness Day started on September 9, 1999 to bring global awareness to Fetal Alcohol Spectrum Disorder (FASD).
This year, Canada FASD Research Network (CanFASD) is launching FASD Awareness Month for all of September. The goal is to bring awareness to what FASD is and challenge the stigma and misinformation surrounding the disability. In preparation, they have released a toolkit with information about FASD, speech-writing tips, and images that are strengths-based, non-judgemental, and person-centered as to reduce the stigma around FASD, alcohol, and pregnancy.
CanFASD’s campaign explores how FASD is many things; including a women’s health issue. Preventing FASD requires supporting women in addressing the issues that contribute to their substance use and experience of trauma. When women receive non-judgemental support that is tangible and offers practical help, women are able to reduce or abstain from substance use, improve their health, and be empowered mothers.
Positioning FASD as a woman’s health issue recognizes:
Communities’ roles in healthy pregnancies;
Service providers’ role in delivering services that women need (i.e. housing, employment, nutrition, anti-violence, substance use) in an accessible and non-judgemental way;
Governmental roles in creating evidence based alcohol policy, and addictions & child welfare policies that prioritize wrapping support around the mother-child unit; and,
Society’s role in learning more about alcohol use in pregnancy and FASD.
In Canada, FASD prevention advocates work together to link up the local, provincial and national efforts through a virtual prevention research network, which receives financial support from the Canada FASD Research Network (CanFASD). Recently CanFASD refreshed their website, so national action on prevention is profiled. See https://canfasd.ca/topics/prevention/
The Prevention Network Action Team on FASD Prevention from a Women’s Health Determinants Perspective (pNAT) has four objectives. To advance prevention research, the pNAT builds multidisciplinary research teams, which develop research proposals, and conduct research, including evaluation research. A second objective is to develop and implement strategies for moving “research into action”, for example through preparing and delivering workshops and curricula (both online and offline), and preparing and distributing policy briefs and reports. A third objective is to influence policy and service provision by proactively and collaboratively working with governments and communities to identify and implement service and policy improvements. It is through the fourth objective of networking and networked learning, that the other objectives are achievable. A virtual, national network becomes a location for sharing knowledge, expertise and skills.
The participants in the Canadian pNAT are inclusive of researchers, service providers,
health system planners, policy analysts, community based advocates and (where possible) mothers with lived experience. To achieve this participation, the pNAT employs a virtual community of inquiry (vCoI) model, supplemented by face-to-face meetings often held in conjunction with national and international conferences. Through the vCoI, participants are able to voluntarily attend monthly webmeetings to:
Share updates on their work;
Learn of recent additions to the evidence on FASD prevention;
Discuss research, service provision and advocacy developments undertaken by members and by others in Canada; and
Plan collective action.
In this way, participants learn together about FASD prevention, and are able to situate their own work within the field.
The community of inquiry framework developed by Garrison and colleagues (2003) provides the foundational, evidence-based design of the virtual community, and grounds it as a ‘learning’ one. In communities of inquiry, people construct meaning through epistemic engagement, as learners, teachers and social connectors (Shea & Bidjerano 2009). In key ways this virtual learning community model reflects the approach that service providers are finding helpful in interactions with mothers and families: i.e. as both teachers and learners, in relationships that prioritize safety, resilience and connectedness.
In addition to the monthly virtual community meetings, the pNAT uses this blog to share outwardly some of the key issues identified in the virtual community. Visit the https://canfasd.ca/topics/prevention/ location to learn more about the pNAT and its many activities.
Garrison, D. R. and T. Anderson (2003). E-Learning in the 21st Century: A framework for research and practice. New York, NY, Routledge Falmer.
Shea, P., & Bidjerano, T. (2009). Community of inquiry as a theoretical framework to foster “epistemic engagement” and “cognitive presence” in online education. Computers & Education, 52(3), 543-553.
Key challenges in FASD prevention are the stigma directed to pregnant women and new mothers who use alcohol and other substances, and the fear of having children removed from mothers’ care if they report their use and/or seek help. A new resource, in toolkit format, Mothering and Opioids: Addressing Stigma – Acting Collaborativelyaddresses these long standing dilemmas for women and for service providers.
This toolkit provides tools, worksheets, and factsheets to aid substance use and child welfare workers in building capacity to offer mother-child centred, trauma informed, culturally safe, and harm reduction-oriented services and policies. The toolkit’s four sections each address a specific area or need in service delivery and provision:
Addressing Stigma in Practice
The first section examines how women who use opioids experience stigma and includes tools for assessing potentially stigmatizing practices. This section also includes a script for responding constructively to coworkers’ stigmatizing behaviour arising from the work of Lenora Marcellus and Betty Poag, as well as a factsheet entitled “10 Things Pregnant and Parenting Women Who Use Substances Would Like Practitioners to Know” created by women with lived experience accessing services at HerWay Home in Victoria BC.
Improving Programming and Services
The second section describes how stigma relates to the barriers that women face. It identifies promising practice and policy responses that address stigma and health, substance use, and child protection concerns. Tools are provided to facilitate integrating promising approaches into our responses, and to identify ways in which barriers can be overcome. It honours and advances the differing roles of substance use services and child welfare services in supporting women and children, as well as evidence informed shared approaches (See diagram from page 21)
Cross System Collaboration and Joint Action
The third section includes information and tools to facilitate cross-system collaboration. Collaboration between the child welfare and substance use fields provides an opportunity to improve child safety and support the recovery of parents. Cohesive working relationships between these sectors can foster advocacy, consultation, system navigation, safety planning, and streamlined referrals. In this, as in all sections there are resources that focus on Indigenous approaches to child welfare and substance use.
The final section discusses policy matters, and how defining and affirming policy values can clarify our work in both systems of care. This section emphasizes viewing mothers and children as a unit when developing policy and programming to facilitate the goal of keeping mothers and children together.
Researchers at the Centre of Excellence for Women’s Health worked with other researchers, service providers and women with lived experience to create a practical and forward looking resource designed to inspire self-reflection and action, to promote an immediate impact on current policy and practice. The tools are designed to help us continue to build on our capabilities to make mothers’ needs and voices central in our work, and to offer mother-child centred, trauma informed, culturally safe and harm reduction-oriented services and policies related to women’s use of alcohol, opioids and all other substances.
Here are four innovative ways that brief discussion about alcohol and other substance use is being expanded:
In Sexual Health
Sexual health clinicians are well positioned to deliver brief substance use interventions due to their open, non-judgmental and harm reduction-oriented model of practice. Sexual health providers are able to discuss substance use together with contraceptive use and/or sexually transmitted and blood borne infections [1, 2]. Conversations about substances, sex, and safety can support a woman’s decisions and confidence for change towards improving health in whatever area fits for her.
Linking Discussion of Multiple Substances
Cannabis legalization provides a ‘window of opportunity’ to engage in discussions about alcohol, tobacco, and cannabis use in pregnancy. Discussing what we know and don’t know about cannabis use in pregnancy can now be linked to open conversations about alcohol and other substance use in pregnancy.
Understanding the Link to Adverse Childhood Experiences (ACEs)
Research on ACEs shows how a history of childhood stressors, including physical, sexual, and emotional abuse, may influence alcohol use among adults including pregnant women . Adopting a trauma-informed approach in conversations about alcohol use in pregnancy supports women who experienced childhood adversity with safety, choices, collaboration, self compassion and skills for change.
Advancing Indigenous Wellness Approaches
Holistic, relational, community-based, and culture-led FASD prevention initiatives are key to wellness for pregnant women in Indigenous communities . These interventions address the broad social and structural determinants of health that are associated with substance use and respond to the Truth and Reconciliation Commission Call to Action #33.
Lane, J., et al., Nurse-provided screening and brief intervention for risky alcohol consumption by sexual health clinic patients. Sexually Transmitted Infections, 2008. 84(7): p. 524-527.
Crawford, M.J., et al., The clinical effectiveness and cost-effectiveness of brief intervention for excessive alcohol consumption among people attending sexual health clinics: a randomised controlled trial (SHEAR). Health Technology Assessment, 2014. 18(8): p. 1-48.
Frankenberger, D.J., K. Clements-Nolle, and W. Yang, The Association between Adverse Childhood Experiences and Alcohol Use during Pregnancy in a Representative Sample of Adult Women. Women’s Health Issues, 2015. 25(6): p. 688 – 695.
Wolfson, L., et al., Collaborative Action on Fetal Alcohol Spectrum Disorder Prevention: Principles for Enacting the Truth and Reconciliation Commission Call to Action #33. International Journal Of Environmental Research And Public Health, 2019. 16(9).
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.