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why-do-girls-and-women-drinkThe Washington Post recently featured an article on the normalisation of heavy drinking for women. Citing targeted advertising and multiple media, particularly to girls on social media, the article outlines the dangers in this trend of treating alcohol as a lifestyle rather than a drug. The obvious dangers are that normalising heavy drinking will increase the number of alcohol-exposed pregnancies and have a negative impact on girls’ and women’s health. Advertising exploits the positive connections women seek with each other, making it about drinking together and promoting it on t-shirts, cups, cards and even wine labels.

The liquor industry is attempting to link drinking with gender equality. But there is nothing equal or liberating about the risks women and girls face, or the distain that is heaped upon them for drunkenness. A recent article in the Daily Mail supported public shaming of binge drinking by young women in particular, and featured numerous denigrating photos of them on New Year’s Eve. Many pointed out the hypocrisy of moralising (Suzanne Moore, The Guardian). A different dialogue is needed: one that focuses on facts, health, education, and creates platforms of conversation and support.

It’s science not sexism that reveals the risks and consequences of heavy drinking for women and girls, and ways to reduce harm. We have learned why women may drink, the effectiveness of non-judgmental approaches to reducing harm, and best practices and policies for promoting health. The facts are not as confusing as some suggest and by focusing on them, we can counter normalising and moralising.

  • Women’s bodies process alcohol differently, so woman’s alcohol level will be higher than a man drinking the same amount. Canada’s low-risk drinking guidelines reflect this sex difference.girls-alcohol-pregnancy-picture
  • Men, in general, are riskier drinkers than women as evidenced by rates of alcohol-related injury and mortality, but women have more chronic health risks related to heavy drinking (Wilsnack & Wilsnack, 2013).
  • Beyond the risk of addiction, Jennie Cook’s research found a causal link between drinking and at least 7 forms of cancer for both sexes (Connor, 2017).
  • Claims of protective factors for cardiovascular disease are coming under scrutiny and skepticism even as these claims remain a core industry research topic and argument for drinking (Chikritzhs, Fillmore, & Stockwell, 2009)
  • How and when we present the facts of drinking alcohol to women and their partners makes a difference to the health of women and their families (See 10 Fundamental components of FASD Prevention from a women’s health determinant perspective).
  • Prevention of alcohol harms requires a tiered response in policy, practice, and messaging (See FASD Prevention: Canadian Perspectives)
  • Comprehensive and integrated programs that build relationships work best for supporting women in making healthy choices for themselves and their families (See Mothercraft’s Mother-Child Study)

References

Chikritzhs, T., Fillmore, K., & Stockwell, T. I. M. (2009). A healthy dose of scepticism: Four good reasons to think again about protective effects of alcohol on coronary heart disease. Drug and Alcohol Review, 28(4), 441-444. doi:10.1111/j.1465-3362.2009.00052.x

Coalescing on Women and Substance Use. http://coalescing-vc.org/virtualLearning/section2/documents/GirlsAlcoholPregnancyinfographic7.pdf

Connor, J. (2017). Alcohol consumption as a cause of cancer. Addiction, 112(2), 222-228. doi:10.1111/add.13477

Wilsnack, R. W., & Wilsnack, S. C. (2013). Gender and alcohol: consumption and consequences. In P. B. Peter Boyle, Albert B. Lowenfels, Harry Burns, Otis Brawley, Witold Zatonski, Jürgen Rehm (Ed.), Alcohol: Science, policy and public health (pp. 153-160). Oxford, England: Oxford University Press.

 

 

 

Each year, researchers with the Prevention Network Action Team (pNAT) of CanFASD Research Network conduct an international literature review of academic articles published on FASD prevention. Rose Schmidt and Nancy Poole of BC Centre of Excellence for Women’s Health looked at articles published between January and December 2015 and compiled a comprehensive bibliography of 88 FASD prevention-related articles – an increase of 25 articles from last year. With this review, those working on FASD prevention will be able to update themselves on the most current evidence and tailor policy and practice accordingly.

The bulk of the articles have come from the U.S., Canada and Australia, the United Kingdom and South Africa, in that order. The articles are organized under the four-level prevention framework created by the pNAT, as well as including articles related to FASD prevalence, influences, issues of preconception, indigenous women and young women. Fourteen articles were assigned to more than one topic category.

A look at “prevalence”

The topic category with the most articles was prevalence, followed in order by brief intervention with girls and women of childbearing age (Level 2), and influences. Preconception, raising awareness (Level 1), and specialized prenatal report (Level 3) also had a significant number of articles. We will highlight these topics individually in this blog over time in order to focus on key components of FASD prevention.

There were 26 articles having to do with prevalence rates as compared to seven articles in that category in 2014. They relate to specific location, U.S., Canada, Uganda, Norway and Tanzania, for instance, as well as pregnancy intentions, characteristics of women at risk for alcohol-exposed pregnancy, women’s understanding of risk factors during pregnancy, rates of binge drinking, adverse childhood experiences, and use of both alcohol and tobacco during pregnancy.

Some of the more compelling findings include:

  • new data from Canada shows that 27% of pregnancies are unintended – useful in that previous data on unintended pregnancies has been from the U.S. only [1];
  • smoking currently or in the past increased the likelihood of consuming alcohol during pregnancy [2];
  • experiences of abuse and violence are associated with higher levels of drinking during pregnancy[3], as well as higher education levels and older maternal age [4-9];
  • a “dose response” relationship was found to exist between adverse childhood experiences and drinking during pregnancy[3], and;
  • smoking during pregnancy was the most consistent predictor of drinking during pregnancy[10] .

Preconception behaviors as they relate to prevalence of alcohol-exposed pregnancies, in general, has become more of a focus in prevention efforts, and will be further discussed in upcoming blog posts on this bibliography.

For more information on FASD Prevention and Prevalence, see these earlier posts:


REFERENCES
  1. Oulman, E., et al., Prevalence and predictors of unintended pregnancy among women: an analysis of the Canadian Maternity Experiences Survey. BMC Pregnancy & Childbirth, 2015. 15: p. 1-8.
  2. Lange, S., et al., Alcohol use, smoking and their co-occurrence during pregnancy among Canadian women, 2003 to 2011/12. Addictive Behaviors, 2015. 50: p. 102-109.
  3. 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.
  4. English, L., et al., Prevalence of Ethanol Use Among Pregnant Women in Southwestern Uganda. Journal Of Obstetrics And Gynaecology Canada: JOGC = Journal D’obstétrique Et Gynécologie Du Canada: JOGC, 2015. 37(10): p. 901-902.
  5. González-Mesa, E., et al., High levels of alcohol consumption in pregnant women from a touristic area of Southern Spain. Journal of Obstetrics & Gynaecology, 2015. 35(8): p. 821-824.
  6. Dunney, C., K. Muldoon, and D.J. Murphy, Alcohol consumption in pregnancy and its implications for breastfeeding. British Journal of Midwifery, 2015. 23(2): p. 126-134.
  7. Kingsbury, A.M., et al., Women’s frequency of alcohol consumption prior to pregnancy and at their pregnancy-booking visit 2001–2006: A cohort study. Women & Birth, 2015. 28(2): p. 160-165 6p.
  8. Kitsantas, P., K.F. Gaffney, and H. Wu, Identifying high-risk subgroups for alcohol consumption among younger and older pregnant women. Journal of Perinatal Medicine, 2015. 43(1): p. 43-52 10p.
  9. Lanting, C.I., et al., Prevalence and pattern of alcohol consumption during pregnancy in the Netherlands. BMC Public Health, 2015. 15(1): p. 1-5.
  10. O’Keeffe, L.M., et al., Prevalence and predictors of alcohol use during pregnancy: findings from international multicentre cohort studies. BMJ Open, 2015. 5(7): p. e006323-e006323.

 

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.

 

WHO report 2014

The Global status report on alcohol and health 2014 from the World Health Organization provides a global overview of alcohol consumption.

It looks at patterns of alcohol use, including binge drinking, and the relationship between alcohol and over 200 health conditions. It also looks at alcohol policy and interventions and provides country-by-country profiles of patterns and trends.

  • Globally, alcohol causes approximately 3.3 million deaths every year (or 5.9% of all deaths); and 5.1% of the global burden of disease is attributable to alcohol consumption. In 2012, 7.6% of deaths among males and 4.0% of deaths among females were attributable to alcohol.
  • While alcohol is the leading risk factor for death in males aged 15–59 years, women are more vulnerable to alcohol-related harm for a given level of alcohol use or a particular drinking pattern. As well, alcohol use among women is continuing to increase and is linked to economic development and changing gender roles.
  • Worldwide, 61.7% of the population (ages 15+) had not drunk alcohol in the past 12 months, and 13.7% had ceased alcohol consumption (i.e. they have consumed alcohol earlier in life but not in the past 12 months).
  • Almost half of the global adult population (48.0%) has never consumed alcohol.

fig 26

Just over 70 countries reported nationwide awareness-raising activities related to alcohol and pregnancy. The report also discusses the role of health services in reducing alcohol-related harm and supports:

  • initiatives for screening and brief interventions for hazardous and harmful drinking at primary health care and other settings, including early identification and management of harmful drinking among pregnant women and women of child-bearing age;
  • improving capacity for prevention of, identification of, and interventions for individuals and families living with fetal alcohol syndrome and a spectrum of associated disorders

For more on global alcohol patterns and trends, see earlier posts:

Making links between substance use and eating disorders

FireShot Screen Capture #247 - 'Road to 'Drunkorexia' - Jacoba Urist - The Atlantic' - www_theatlantic_com_health_archive_2013_03_road-to-drunkorexia_274205

The Atlantic published an interesting article last week called “Road to ‘Drunkorexia’ – The downsides of the weight-conscious alcohol boom.” (March 27, 2013, Jacoba Urist).

I’ve blogged in the past about the phenomenon of dieting or overexercising to ‘save’ calories for drinking later on. (See earlier posts Drunkorexia: Binge drinking and disordered eating on college campuses (October 27, 2010) and “Drunkorexia”: an update on binge drinking and disordered eating from The Fix (November 1, 2011)).

The article in The Atlantic provides an update on drunkorexia and comments on a trend in alcohol marketing focusing on calories and weight concerns.

Shape magazine (www.shape.com) lists Bud Select 55 as one of 15 bikini-friendly beers.

Shape magazine (www.shape.com) lists Bud Select 55 as one of 15 ‘bikini-friendly’ beers.

Sarah Beller at The Fix in ” ‘Drunkorexia’ is Double Trouble” (April 1, 2013) comments on the relatively common co-occurence of disordered eating and substance abuse. She interviews Dr. Harris Stratyner, Vice President of Caron Treatment Centers, who comments:

“The thing that worries me…is the combination of the two. Alcohol robs you of very important vitamins—such as Vitamin A, B12, and folate. And anorexia, bulimia, and over-exercising rob you of some of the same vitamins at an additional volume. We’re seeing girls and women destroying their reproductive systems, getting calcium deficiencies. It’s frightening to me as a doctor.”

This link between alcohol misuse and malnutrition is an important one for those of us working in FASD prevention. We know that nutrients such as zinc, vitamin A, folate, and choline can help protect a developing fetus from the harms of alcohol.

For more on weight-conscious alcohol marketing to women, see earlier posts:

ottawa parliament

As approximately 4% of all deaths worldwide can be attributed to alcohol consumption, governments around the world are looking for policy approaches that can reduce the harms of alcohol use and misuse at a population level.

One policy approach that governments are increasingly looking at is minimum alcohol pricing. Minimum alcohol prices help to avoid situations where very low prices entice individuals into purchasing and consuming more alcohol than they otherwise might. Minimum price policies can also help set prices in relation to the percentage of alcohol content that a product has — higher prices for higher alcohol content.

There is strong and growing evidence that:

  • reduced alcohol consumption lowers rates of alcohol-related illnesses, injuries and social problems;
  • high-strength products are associated with risky patterns of alcohol consumption;
  • younger and heavier drinkers tend to choose cheaper alcohol.

So, what does minimum pricing have to do with FASD prevention? Quite a lot actually. An individual woman’s pattern of alcohol consumption is deeply connected to the context in which she lives. A woman’s drinking patterns can be affected by the drinking patterns of her friends and partner, the typical drinking practices in the part of the country where she lives, the packaging size of alcoholic beverages, alcohol advertising legislation, and the geographic density of outlets that sell alcoholic beverages – just to name a few things. Many of these factors can be greatly influenced by policy.

Looking at alcohol policy as a solution to FASD prevention also allows us to shift from focusing on individual women (which often results in a lot of blaming, guilt, and pressure on pregnant women) and to find broader solutions that affect communities and populations and have many positive outcomes, not just a reduction in FASD.

Nootka Sound

A research study published this week in the journal Addiction provides more evidence to support minimum alcohol prices. Researchers from the Centre for Addictions Research of BC at the University of Victoria found that between 2002 and 2009, the percentage of deaths caused by alcohol in British Columbia dropped more than expected when the minimum alcohol price was increased. A 10% increase in the average minimum price for all alcoholic beverages was associated with a 32% reduction in wholly alcohol attributable deaths (this includes things such as alcohol abuse, poisonings due to alcohol, excess alcohol blood level). You can take a look at the press release (Feb 7 2013) for the study here.

This latest study shows that even the heaviest of drinkers reduce their alcohol consumption when minimum alcohol prices increase – an important finding for those concerned with FASD prevention. You could think of it as a different form of harm reduction.

The study is also interesting as it gives some insight into debates about how alcohol is sold. Over the time period for this study, policies changed to allow for the partial privatization of alcohol retail sales resulting in a substantial expansion of private liquor stores. (Previously in British Columbia, alcohol could only be sold directly to the public in government-owned stores, unlike in Europe or the USA where it is often widely available in supermarkets, gas stations, etc.). The researchers found that a 10% increase in private liquor stores was associated with a 2% increase in acute, chronic, and total alcohol attributable deaths mortality rates.

For more on alcohol policy and FASD prevention, see earlier posts:

References

Stockwell T, Auld MC, Zhao JH, Martin G. (2012). Does minimum pricing reduce alcohol consumption? The experience of a Canadian province. Addiction, 107(5):912- 920.

Stockwell T, Zhao J, Giesbrecht N, Macdonald S, Thomas G, Wettlaufer A (2012). The raising of minimum alcohol prices in Saskatchewan, Canada: Impacts on consumption and implications for public health. American Journal of Public Health, 102(12): e103-10. doi: 10.2105/AJPH.2012.301094. Epub 2012 Oct 18. See the press release for this study here.

Zhao J, Stockwell T, Martin G, Macdonald S, Vallance K, Treno A, Ponicki W, Tu A, and Buxton J. (2013) The relationship between changes to minimum alcohol prices, outlet densities and alcohol attributable deaths in British Columbia in 2002-2009. Addiction, 108: doi:  10.1111/add.12139

Source: The Council of Aboriginal Elders of SA website, http://www.caesa.org

The National Indigenous Drug & Alcohol Committee (NIDAC) in Australia has a great article on their website on Locally designed and operated Indigenous community models. The article states:

“The benefit of locally designed and operated initiatives is that they can be tailored to community needs and in a cultural context that is owned and supported by the community. This enhances the strengths and builds resilience of a community and combined with the added support of services provides for a more sustainable and long term solution.”

One of the programs profiled in the article is The Grannies Group.

The Grannies Group in South Australia is a peer support network of senior Aboriginal men and women who advocate on behalf of issues affecting their children, grandchildren and their community. Part of their work includes raising awareness of drug and alcohol issues through community education sessions using their own stories and issues.

In a radio interview in May 2012, 75-year-old Grannies Group member Coral Wilson describes the founding of the group:

“We sort of got together and talked about how we can come to terms with the drug abuse that’s in our community and within our families. It wasn’t that we had to set up this group straight away it was a lot of talking between ourselves about, what are we going to do with him? What are we going to do with her? They’re in jail, we’ve got to look after the kids and so on. And that brought about this group coming together, and it was to support, support each other because of the problems we all had with our children on drugs and alcohol. And it’s been going for well over ten years now. “

The Grannies Group is part of the Council of Aboriginal Elders of South Australia and is supported by the Australian Government’s Home and Community Care (HACC) program.

See the press release Elders take a stand against alcohol abuse (September 12, 2012). You can also take a look at the NIDAC report Addressing fetal alcohol spectrum disorder in Australia (2012).

Risky drinking declining faster in girls than boys?

Last week, German Health Minister Daniel Bahr (FDP) and the Federal Centre for Health Education (BzgA) announced a country-wide decline in binge drinking in teenagers and provided an update on the “Alkohol? Kenn dein Limit” campaign.

In 2009, BZgA started a campaign called “Alkohol? Kenn dein Limit” (Alcohol? Know your limit), with financial support from an association of private health insurance companies (about 50 million Euros over three years). The campaign focuses on 16-20 year olds and aims to reduced  binge drinking and risky patterns of alcohol use by increasing awareness about the risks and dangers of alcohol misuse. The campaign includes billboards, TV and cinema ads, brochures, and Facebook.

A year before the campaign started, researchers found that 20% of teenagers (ages 12-17) said they drank five alcoholic drinks or more once a month or more. A recent survey in 2011 suggests that this figure has dropped to approximately 15%. Health Minister Daniel Bahr reports that alcohol is the most widely used substance in Germany; in 2010, approximately 26,000 teenagers between 16 and 20 had been treated in hospital for acute alcohol poisoning.

Interestingly, there appears to be sex differences in the overall decline in teenagers. The decline appears primarily related to changes in drinking practices of girls and in 12-15 year old boys. In 2008, 34% of girls reported drinking more than five drinks at a time once a month; in 2011, this decreased to 22%. There was little change in rates for 16-17 year old boys, who drink the most (almost half drink 5 or more drinks once a month or more).

In the age 18-25 group, more than 50% of young men reported drinking more than five drinks in one night during the previous month – twice that of young women.

Due to these reported sex differences in drinking practices, the next stages of the campaign (which is currently planned to continue for another year) will switch its strategy and use different messages, images and design to target girls versus boys. Check out the campaign website here to take a look. The website does include information/brochures for download on pregnancy and alcohol although this is not a focus in the campaign.

Germany’s 2012 National Drug Strategy includes goals related to reducing the frequency of binge drinking among children and adolescents and abstinence from alcohol during pregnancy. Learn more here.

For more coverage of the campaign, see:

Making the link between unintended pregnancies and FASD prevention

The Centers for Disease Control and Prevention (CDC) in the United States released two reports this month with new data on alcohol consumption during pregnancy and unintended pregnancies. It’s interesting to take a look at these reports side-by-side as they suggest completely different target groups for FASD prevention activities.

The first report looked at alcohol use and binge drinking among women of childbearing age. The researchers found that approximately 7.6% (or 1 in 13) of pregnant women consume alcohol during pregnancy and that 1.4% of pregnant women binge drink. Interestingly, non-pregnant women and pregnant women had similar patterns of binge drinking: about three times per month and approximately six drinks on an occasion.

Among pregnant women, the highest prevalence estimates of reported alcohol use were among those who were aged 35–44 years (14.3%), “white” (8.3%), college graduates (10.0%), or employed (9.6%).

In 2005, the Surgeon General issued an advisory urging women who are pregnant or who might become pregnant to abstain from alcohol use. Currently, the CDC advises: “Because no safe level of alcohol during pregnancy has been established and alcohol is known to cause birth defects, developmental disabilities, and other adverse pregnancy outcomes, women who are pregnant or who might become pregnant should refrain from drinking alcohol.”

It’s the last part of this advisory targeted at “women who might become pregnant” that leads us to the second report.

Generally speaking, it is believed that 1/3 to 1/2 of pregnancies are unintended. This report found that about 37% of births in the United States were unintended at the time of conception. While this statistic hasn’t changed much since the early 1980s, the groups with the highest rates of unintended pregnancies have changed (you can take a closer look at the report for more – see the link below).

Unintended pregnancies include both pregnancies that are unwanted, and those are mistimed, meaning the woman said she wanted to become pregnant at some point, but not at the time she did.

There’s a lot of reasons why a women becomes pregnant unintentionally and contraception use is one of them. The researchers found that 40% of women were using contraception and 60% were not. The researchers asked women who were not using contraception at the time they conceived about their reasons. They found that:

  • 35.9 percent said they did not think they could get pregnant
  • 23.1 percent said they would not mind if they became pregnant
  • 17.3 percent said they had not expected to have sex
  • 14.3 percent said they were worried about the side effects of using birth control

In terms of men, 8% said their male partner did not want to use birth control himself, and 5.3 percent said their male partner did not want them to use birth control.

So, it’s interesting to think about, right?

  • 52% of women of childbearing age consume alcohol
  • 37% of pregnancies are unintended (which means these women were unlikely to change their alcohol consumption)
  • Of women who become pregnant unintentionally, 60% were not using contraception.

These data suggest that we need to be looking at alcohol use, especially risky alcohol use like binge drinking, way before conception. It also suggests that many women need additional support around their fertility and finding contraception that works for them (and that perhaps their male partners might want to get involved in some of these issues??)

References

Marchetta, C.M., Denny, C.H., Floyd, L., Cheal, N.E., Sniezek, J.E., McKnight-Eily, L.R. (2012). Alcohol Use and Binge Drinking Among Women of Childbearing Age — United States, 2006–2010. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report (MMWR), 61(28): 534-538.

Mosher, W.D., Jones, J. and Abma, J.C. (2012). Intended and Unintended Births in the United States: 1982–2010. National Health Statistics Reports, No. 55. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.

Overview: Four Levels of FASD Prevention

Information Sheet: What Men Can Do To Prevent FASD

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