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Many women who have FASD are able to benefit from tailored support on substance use problems. Audrey McFarlane, Executive Director of Lakeland Centre for FASD in Cold Lake AB recently shared strategies for working on FASD prevention with women who have FASD themselves. One of the LCFASD programs, the 2nd Floor Women’s Recovery Centre, provides residential treatment exclusively to women. She explained how programs can better support women who have FASD.
Challenges
Because of the possible neuro-behavioural and physical health issues associated with FASD, working with women living with FASD may pose particular challenges for the service provider due to:
- Limited understanding of how their body works and how or why to use birth control;
- Limited understanding of how to get housing, money and to keep themselves safe;
- Physical health issues, such as diabetes, STDs, vision, hearing and dental;
- Limited ability to envision the future;
- Inability to link actions to consequences, which makes them more likely to be connected to the justice system and to have many children not in their care with multiple partners.
Strategies
McFarlane says that these and other challenges mean it often takes longer to see the benefits of supports. Yet, there are a number of strategies that have proven successful.
- Take a family alcohol history and ask each woman, specifically, if she has a diagnosis of FASD. Woman will tell you if they do, but are often not even asked.
- Make suggestions in key areas where they can agree or disagree rather than using client-generated approaches.
- Prioritize building a relationship so that the woman will come back for support as needed. Reframe returning to treatment as a positive, not a negative.
- Expect to spend more time on basic life skills and necessities. She may not have connection to family or social services. This means treatment needs to be longer.
- Approaches that work best include solution-focused counselling, physical activities, positive touch, relaxation, and connections that develop a sense of belonging, like volunteering and cultural practices.
Resources
Here are a number of resources on trauma-informed and FASD-informed approaches for working with women living with FASD.
FASD Informed
2 Reports on Substance Using Women with FASD and FASD Prevention: Voices of Women and Perspectives of Providers, prepared by Deborah Rudman
Evaluation of FASD Prevention and FASD Support Programs website
FASD Informed Approach by Mary Mueller, RN, Waterloo Region Public Health and Emergency Services
FASD Informed Practice for Community Based Programs, College of New Caledonia
Working with Women Who May Have FASD Themselves – Webinar View Slides – Recording
Trauma Informed
Pregnancy, Alcohol, and Trauma-informed Practice, The Prevention Conversation
Trauma-informed Approaches to FASD Prevention – Webinar View Slides – Recording
Trauma-Informed Practice Resource List, Centre of Excellence for Women’s Health
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For more on this topic, see earlier posts:
WEBINAR JUNE 23 – WORKING WITH PREGNANT AND PARENTING WOMEN: LEARNINGS FROM HERWAY HOME, June 16, 2016
NEW CURRICULUM FOR FASD INFORMED PRACTICE, August 1, 2016
THE MOTHER-CHILD STUDY: EVALUATING TREATMENTS FOR SUBSTANCE-USING WOMEN, March 18, 2015
FACT SHEET ON SUPPORTING WOMEN WITH FASD IN RESIDENTIAL SUBSTANCE ABUSE TREATMENT, April 22, 2013
TRAUMA MATTERS: GUIDELINES FOR TRAUMA‐INFORMED PRACTICES IN WOMEN’S SUBSTANCE USE SERVICES, April 17, 2013
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.
For instance, these four recent headlines:
Drinking alcohol during pregnancy could have transgenerational effects
Prenatal exposure to alcohol increases likelihood of addiction later in life
Any alcohol consumption during pregnancy affects craniofacial development
Foetus absorbs mother’s alcohol and nicotine intake in just 2 hours
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
This real headline deserves more coverage: “ If we want to save lives, control alcohol. ”
We have lots of information of the risks of alcohol-exposed pregnancies. The work now is about prevention and we will work to bring you those “headlines.”
For more information on these topics, see these previous posts:
REACHING AND ENGAGING WOMEN: WHAT WORKS AND WHAT’S NEEDED May 15, 2017
THUNDER BAY’S FAMILY HEALTH PROGRAM PUBLISHES RESEARCH REPORT FOR PREVENTING ALCOHOL-EXPOSED PREGNANCY October 4, 2016
THE WORK OF THE NETWORK ACTION TEAM ON FASD PREVENTION FROM A WOMEN’S HEALTH DETERMINANTS PERSPECTIVE (CANFASD RESEARCH NETWORK) April 11, 2016
FASD ISSUE PAPERS FROM THE CANADA FASD RESEARCH NETWORK PROVIDE A QUICK OVERVIEW OF RECENT RESEARCH December 1, 2014
SUPPORTING PREGNANT WOMEN WHO USE ALCOHOL OR OTHER DRUGS: A GUIDE FOR PRIMARY HEALTH CARE PROFESSIONALS MAY 15, 2016
FREE WEBINAR: UPDATED RESOURCES ON WOMEN AND ALCOHOL: APPLYING RESEARCH TO PRACTICE – MAY 8, 2014 April 21, 2014
FASD PREVENTION RESEARCH AND KNOWLEDGE TRANSLATION: DEVELOPING A PAN-CANADIAN AGENDA WORKSHOP January 29, 2014
FASD INFORMED PRACTICE FOR COMMUNITY BASED PROGRAMS March 27, 2014
RESEARCH MAKES LINKS BETWEEN GENDER, ETHNICITY, CHILDHOOD ABUSE AND ALCOHOL USE April 2, 2013
TRAUMA MATTERS: GUIDELINES FOR TRAUMA‐INFORMED PRACTICES IN WOMEN’S SUBSTANCE USE SERVICES April 17, 2013
Individuals with FASD and women who use alcohol and drugs during pregnancy have long been targets of both overt and unconscious stigma. We know that stigma can undermine FASD prevention and intervention efforts by assigning underserved blame, simplifying a complicated issue, and focusing on deficits rather than building on strengths. Women who are shamed are often afraid to seek services, which undermines prevention efforts. Recognizing this problem, the 14 Manitoba FASD Coalitions across the province created the “Looking After Each Other: A Dignity Promotion Project” in 2014 to “promote the dignity of those with FASD and their families.”
The Looking After Each Other project completed two new resources recently to add to their previous activities. One is the FASD Language Guide in both English and French that explains how and why the way we talk about FASD can be stigmatizing. The guide reviews certain commonly used words and phrases and offers alternatives. Some phrases were once the preferred term, but have been rethought over time. For instance, framing the issue of women using alcohol and drugs as “choosing to use” blames women by failing to recognize complicating factors such as mental health, addiction, or abuse issues that make it difficult to stop using during pregnancy.
The other new resource is a mini documentary that was made in collaboration with The Mothering Project in Winnipeg. Entitled “Meeting Women Where They Are At: Community Making a Difference,” it features several women who participate in the programs and services of the Mothering Project. By sharing their stories, viewers come to understand what these women have overcome, how they have built healthy relationships with themselves, their communities, and their children, which helps to dispel conscious and unconscious biases. As Tammy Rowan, Program Manager, explain the Mothering Project takes a relational approach to supporting women in their lives and as parents. Watch the mini documentary here.
For more information, see earlier posts:
COERCIVE MESSAGING FOR PREGNANT WOMEN? June 2, 2017
REACHING AND ENGAGING WOMEN: WHAT WORKS AND WHAT’S NEEDED May 15, 2017
CONVERSATIONS ON ALCOHOL: WOMEN, THEIR PARTNERS, AND PROFESSIONALS April 23, 2017
FASD PREVENTION WITH INDIGENOUS COMMUNITIES IN AUSTRALIA April 3, 2017
FIRST-EVER FASD PREVENTION PLENARY AT THE 7TH INTERNATIONAL CONFERENCE ON FASD March 22, 2017
NEW FACILITATOR’S FASD TRAINING GUIDE FOR FIRST NATIONS WOMEN January 3, 2017
NEW ZEALAND’S NEW ACTION PLAN TO ADDRESS FASD September 17, 2016
“SUPPORTING PREGNANT WOMEN WHO USE ALCOHOL OR OTHER DRUGS: A GUIDE FOR PRIMARY HEALTH CARE PROFESSIONALS” May 15, 2016
THE MOTHERING PROJECT/MANITO IKWE KAGIIKWE IN WINNIPEG, MANITOBA May 1, 2015
2nd in Series: First-ever FASD Prevention Plenary at the 7th International Conference on FASD: PART 1
“Evidence for multi-faceted, culturally relevant, community-led approaches” – Dr. James Fitzpatrick, Head, and Kaashifah Bruce, Program Manager of Telethon Kids Institute’s FASD Research; June Councillor, CEO of Wirraka Maya Aboriginal Health Services; Anne Russell, Russell Family Fetal Alcohol Disorders Association
Making FASD History newsletter
The “Make FASD History in the Pilbara” program in Western Australia is the result of community-led and culturally relevant efforts within Indigenous communities dealing with the effects of long-term colonization and FASD. It was developed in collaboration and partnership with communities in the Fitzroy Valley and provides strategies and programs to assess and diagnose FASD, as well as to provide health, educational, and management supports to mothers and children.
James Fitzpatrick described earlier successes that underpin this program – like the Lilliwan prevalence project, the PATCHES program to diagnose FASD, and the Marlu Strategy for prevention and intervention (See Video). Dr. Fitzpatrick was nominated in 2016 for the WA Australian of the Year award for his work on FASD.
June Councillor explained the role of the “’Warajanga Marnti Warrarnja” Project – translation Together We Walk This Country – in the strategy and its long-term approach. She featured a video of the project in her remarks. View the program launch Video here.
Kaashifah Bruce presented evaluation results of using this multi-pronged approach that show an increase in: 1) awareness of FASD and the harms caused by drinking in pregnancy; 2) intentions to NOT drink during future pregnancies; and, 3) intentions to help pregnant women not to drink. The encouraging results suggest that this community-led, multi-strategy approach can serve as a blueprint for success in other Aboriginal communities.
LtoR: June Councillor, Anne Russell, Kaashifah Bruce, and James Kirkpatrick
Finally, Anne Russell provided a lived-experience viewpoint with examples of how stigma and stereotyping impede prevention efforts. By describing her own as well as other women’s experiences, she underscored how important it is to avoid stereotypes about women and drinking, and to talk with women and communities about what they need and what is important to them.
For more on FASD prevention in Western Australia, see earlier posts:
Alcohol Think Again Campaign in Western Australia (June 19, 2012)
Films from the Lililwan Project: Tristan and Marulu (May 9, 2012)
FASD Campaign from Kimberley and Pilbara Regions of Western Australia (October 22, 2012)
FASD Prevention in Australia’s Ord Valley (October 13, 2011)
Targeting Health Professionals in Western Australia (February 9, 2011)
Getting Fathers Involved (January 4, 2011)
More Activism from Australia (October 19, 2011)
Yajilarra: the story of the women of Fitzroy Crossing (October 15, 2010)
FASD Initiatives in Western Australia (September 15, 2010)
The World Health Organization’s regional office for Europe has published Prevention of harm caused by alcohol exposure in pregnancy: Rapid review and case studies from Member States.
In this report it is stated that Europe has the highest level of alcohol consumption in the world, and that the gender gap in drinking, and in binge drinking, among young people has narrowed.
Looking over the past decade, the report features a review of 29 research studies and details current FASD prevention efforts of Finland, Germany, Lithuania, Luxembourg, Norway, Poland, Slovenia and Sweden. Studies included in the report were based on Recommendation 2 of the WHO Guidelines for the identification and management of substance use and substance use disorder in pregnancy, which calls for prevention of alcohol consumption in the general population of pregnant women through brief interventions. Consequently, the review excluded studies of alcohol-dependent women.
For women who may become pregnant, interventions related to both risky drinking and contraception were reviewed, such as CHOICES, EARLY and BALANCE.
For pregnant women, interventions to abstain from or reduce alcohol use, or to raise awareness were reviewed. Two of the studies with pregnant women included their partners and showed positive results regarding women reducing their drinking and partners supporting non-drinking.
Case studies of prevention efforts from the 8 profiled countries describe national awareness campaigns; screening and specialized treatment in clinical practice guidelines; national strategy/policy planning and implementation; and post-partum support including for those affected by FASD. The report features a table that illustrates country-specific levels of FASD awareness, which can assist in developing focused strategies.
For more on related topics, see earlier blogs:
DANISH CAMPAIGN SUGGESTS THAT EVERYONE “STICK A CORK IN IT” ON OCTOBER 11TH, October 11, 2012
SPECIALIZED TREATMENT AND CARE FOR PREGNANT WOMEN WITH SUBSTANCE ABUSE PROBLEMS AND THEIR CHILDREN IN HAGA, GOTHENBURG, SWEDEN, November 15, 2012
WORLD HEALTH ORGANIZATION RELEASES THE FIRST EVIDENCE-BASED GLOBAL GUIDELINES TO PREVENT AND TREAT SUBSTANCE USE BY PREGNANT WOMEN, April 28, 2014
GLOBAL STATUS REPORT ON ALCOHOL AND HEALTH 2014 – WORLD HEALTH ORGANIZATION, July 24, 2014
PLANNING AND IMPLEMENTING SCREENING AND BRIEF INTERVENTION FOR RISKY ALCOHOL USE: A STEP-BY-STEP GUIDE FOR PRIMARY CARE PRACTICES FROM THE CDC, August 4, 2014
HOLISTIC AND SPECIALIZED SUPPORT FOR PREGNANT WOMEN: LEVEL 3 PREVENTION, November 21, 2016
Dorothy Badry was honoured by the Premier’s Council on the Status of Persons with Disabilities for Alberta on December 2nd. Dorothy has been a long-time advocate, researcher and educator on the impact of FASD (and a dedicated member of the Prevention Network Action Team). Her work has contributed to FASD being recognized as a disability. For families and individuals affected by FASD, that recognition has made a huge difference.
In a University of Calgary article written about her, she describes FASD as an health “outcome” – a key shift from early stigmatizing assessments. This allows for a relational approach that includes women, children, families, and communities and for inclusive and multi-level prevention/intervention strategies.
An original member of the Canada FASD Research Network, we have benefited from Dorothy’s active participation and counsel. She has been featured in some of our previous blogs for her work at with University of Calgary, Alberta province, and several FASD-related programs. We are happy to feature her once again for this well-deserved honour. Congratulations, Dorothy Badry.
For related blogs, see previous postings:
“Developing Services for Canadians Living with FASD” interview with Dorothy Badry on Family Caregivers Unite! January 5, 2015
Alberta’s PCAP Women’s Quilt: “Creating a bond . . . Building a relationship” April 22, 2016
The work of the Network Action Team on FASD Prevention from a Women’s Health Determinants Perspective (CanFASD Research Network) April 11, 2016
Webinar: “Caregiving, FASD, and Alcohol: Caring about FASD Prevention” – September 9, 2015 August 25, 2015
First Peoples Child & Family Review journal: Special Issue on FASD December 9,
Case Management to Prevent Fetal Alcohol Spectrum Disorder September 20, 2013
Women’s health and FASD prevention in a special issue of the International Journal of Circumpolar Health August 6, 2013
Brightening Our Home Fires: An FASD Prevention and Women’s Health Project in Canada’s Northwest Territories May 6, 2013
The 5th International Conference on Fetal Alcohol Spectrum Disorder: Special Session on FASD Prevention January 14, 2013
Look for us at the 5th National Biennial Conference on Adolescents and Adults with FASD (April 18-21, 2012) April 9, 2012
FASD ANNOTATED BIBLIOGRAPHY 2015, PART 3
FASD Prevention: An Annotated Bibliography of Articles Published in 2015 organizes articles based on the four levels of prevention. 
We’ve been featuring some of those articles and in this post we narrow in on Level 3 FASD prevention efforts – specialized holistic support available to pregnant women with alcohol and other health or social problems. Following are a few of the bibliography articles with that research focus.
Two studies from South Africa underscore the interconnections of alcohol use in pregnancy and the benefits of integrated and holistic services for pregnant women. A large study done in Cape Town, randomly assigned all pregnant women in 24 low-income neighbourhoods either to standard care or to a home-visiting intervention. In total over 1,000 mothers were assessed during pregnancy and at 18 and 36 months post-partum with positive findings for those receiving the home-visiting intervention. 
The authors find that a significant relationship exists over time between alcohol use, partner violence and depression, and they recommend integrated interventions [1]. Similarly, a case management intervention for 67 pregnant women using Motivational Interviewing, Community Reinforcement Approach and life management reduced heavy drinking in pregnancy [2].
Marcellus, MacKinnon et al. through their work with the HerWay program in BC, Canada, “reenvision” success when working with pregnant women with problematic substance use. They identify a holistic range of indicators for success, not only for program participants, but for service providers, community partners and system leaders [3]. This kind of harm-reduction model is getting more attention in the USA. Kramlich & Kronk reviewed six such programs over the last 10 years and conclude that “comprehensive, integrated multidisciplinary services for pregnant women with substance use disorder aimed at harm reduction are showing positive results.”[4]
Torchalla, Linden et al. conducted interviews in the Downtown Eastside of Vancouver, Canada, with 27 pregnant or post-partum women seeking harm-reduction services. They found that multiple forms of trauma were pervasive, ongoing, and reinforced in most areas of the women’s lives. Yet, most of the women did not want trauma-specific counseling when offered it. This underscores, according to the authors, the need for multi-focused, trauma-informed, harm-reduction interventions that broaden their focus to include gender-based violence and human rights [5].
Whitaker provides an overview of the World Health Organization (WHO) guidelines on substance use during pregnancy [6]. The author identifies some of the limitations of the guidelines including effectiveness of varying treatment approaches, knowledge gaps, and ethical issues, yet calls the guidance essential reading for practitioners working with women, children and families where substance use is involved.
Findings show that relational, holistic/integrated, and trauma-informed approaches are effective ways to support substance using women and their families. Yet, training, education and support of practitioners who work with them are vital. Additionally, more research in a number of specific areas is needed.
Find out more about these journal articles as well as articles for all four levels of FASD prevention in The Annotated Bibliography.
REFERENCES
- Rotheram-Borus, M.J., et al., Alcohol use, partner violence, and depression: A cluster randomized controlled trial among urban South African mothers over 3 years. American Journal of Preventive Medicine, 2015. 49(5): p. 715-725.
- de Vries, M.M., et al., Indicated Prevention of Fetal Alcohol Spectrum Disorders in South Africa: Effectiveness of Case Management. International Journal Of Environmental Research And Public Health, 2015. 13(1).
- Marcellus, L., et al., Reenvisioning success for programs supporting pregnant women with problematic substance use. Qualitative Health Research, 2015. 25(4): p. 500-512.
- Kramlich, D. and R. Kronk, Relational care for perinatal substance use: A systematic review. MCN, the American Journal of Maternal Child Nursing, 2015. 40(5): p. 320-326.
- Torchalla, I., et al., “Like a lots happened with my whole childhood”: violence, trauma, and addiction in pregnant and postpartum women from Vancouver’s Downtown Eastside. Harm Reduction Journal, 2015. 12(1): p. 1-10.
- Whittaker, A., Guidelines for the Identification and Management of Substance Use and Substance Use Disorders in Pregnancy. Drug & Alcohol Review, 2015. 34(3): p. 340-341.
Federal, provincial, and territorial ministers met in Halifax, Nova Scotia, on October 14-5 to discuss issues of justice and public safety in Canada including the impact of FASD. Co-chairs of the meeting were Minister of Justice and Attorney General, Jody Wilson-Raybold, Minister of Public Safety and Emergency Preparedness, Ralph Goodale, and the Minister of Justice and Atto
rney General of Nova Scotia, Diana Whalen. Five national indigenous groups participated in the meeting: the Native Women’s Association of Canada, the Assembly of First Nations, the Métis National Council, Inuit Tapiriit Kanatami, and the Congress of Aboriginal Peoples.
Vice-Chief Kim Beaudin from the Congress of Aboriginal Peoples outlined the groups’ priorities to the ministers. Stating that “the most significant issue is violence against women and girls” Beaudin further stressed related issues of FASD, Indigenous girls’ health and safety, violence against Indigenous women, and family justice reforms for Indigenous women.
During the meeting, Ministers discussed the Truth and Reconciliation Commission of Canada: Calls to Action. It underscores the need to address FASD in action numbers 33 and 34, in particular. Ministers agreed to collaborate on addressing solutions for the economic and social impacts of alcohol abuse and to release their final report on FASD and Access to Justice.
FASD prevention efforts in Canada call for multiple approaches that are holistic and move beyond just advising women not to drink during pregnancy (See: Four-part Model of Prevention). The impact of violence and trauma in all its forms on the mental and physical health and safety of women and their families and communities informs and shapes these efforts.
For more on related topics, see earlier blog posts:
- Adverse childhood experiences and alcohol use during pregnancy (August 18, 2015)
- What is the role of women’s experiences of violence and trauma on alcohol use during pregnancy? (May 31, 2014)
- Understanding the links between FASD and early life trauma in indigenous communities in Australia (July 11, 2012)
- Postcolonial theory for beginners (September 1, 2010)
As part of the work of the Family Health Program, the Thunder Bay District Health Unit has published results from a research project on best practices to preventing alcohol-exposed pregnancy. Alongside reviewing literature, they looked at practices both in their health unit and among local community programs and services, and at provincial public health standards.
Seven over-arching themes were identified for a multi-pronged approach to preventing FASD:
1. Population Health Surveillance
2. Public Awareness
3. Public Programs
4. Education for Health Care and Social Service Providers
5. Screening and Intervention by Health Care and Social Services Providers
6. Partnerships
7. Policy/Government Directives (1)
The report targets gaps to be addressed within each of these themes. As an example, within “Public Programs” there is a call to expand or develop programming that is culturally based and that includes women’s partners, and within “Education” to replace generalized training and education with approaches that target specific provider needs.
The authors caution readers not to “dilute the alcohol and pregnancy focus” when incorporating recommendations into existing service structures, and stress that additional research and evidence of programming, policy, and partnerships is needed.
Download the full report here to read more about their research methods, findings and recommendations, and to explore linkages with the Ontario Public Health Standards for reproductive health.
REFERENCES
- Thunder Bay District Health Unit, Family Health Program. (2016). Effective interventions and strategies to prevent alcohol-exposed pregnancies. Thunder Bay, ON.
New Zealand has published an action plan on how best to address FASD. Described as a “whole of government action plan” by Associate Minister of Health, Peter Dunne, Taking Action on Fetal Alcohol Spectrum Disorder: 2016-1019 builds on the best practices being done across communities and service sectors including government policy and partnerships, as well as front line prevention and intervention. According to Fetal Alcohol Network NZ, the government is earmarking an initial 12 million for these efforts, which will increase support and services to women with alcohol and substance use issues.
New Zealand began the process of building the action plan with a discussion document of principles, priorities and action areas. They spent over a year seeking submissions and comments on the plan from professionals, communities, families and whānau (Maori extended family.) Notable changes to the principles based on those submissions included issues of ethnic and services inequities, as well as stigmatization of women, families and individuals with FASD. The resulting principles defined the core priorities of the plan: prevention, early identification, support and evidence. These priorities framed its action building blocks and designated indications of success of plan outcomes. You can view an analysis of the Ministry of Health action plan submissions here.
By underscoring a collaborative and practical approach, the goal is to make sure that “FASD is prevented and people with FASD and their family/whānau live the best possible lives.”(1) Read more about New Zealand’s efforts:
http://www.health.govt.nz/publication/taking-action-fetal-alcohol-spectrum-disorder-2016-2019-action-plan
To read more about New Zealand’s prevention efforts see these previous posts:
First FEBFAST and Debates about Alcohol Labeling in New Zealand, February 1, 2011
References
- FASD Working Group. 2016. Taking Action on Fetal Alcohol Spectrum Disorder: 2016–2019: An action plan. Wellington, NZ: Ministry of Health.
