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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

IMPART info sheet on “Youth, Gender and Substance Use” recaps how the harms of early substance use are gender-specific.

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.
Canadian Centre on Substance Use and Addiction (CCSA) has created a low-risk drinking guide for youth.

Online sexual health resources for youth:

Teen Health Source Native Youth Sexual Health Network

  1. 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
  2. Chakravarthy, B., Shah, S., & Lotfipour, S. (2013). Adolescent drug abuse – Awareness & prevention. The Indian Journal of Medical Research, 137(6), 1021–1023.

A lot of progress has been made on effective FASD awareness and prevention strategies. Early efforts often used disrespectful tactics like unsettling pictures of women slugging down alcohol from a bottle while pregnant with a caption such as “Baby or the Bottle.” Those approaches have largely been abandoned. But one overly simple statement still pops up. And that is, “FASD is 100% Preventable.”

That statement is misleading because it suggests that FASD prevention is unidimensional and linked only to alcohol consumption. But alcohol use during pregnancy is linked to the social determinants of health, and its effects can be exacerbated by food insecurity, trauma, poverty and multi-substance use. It also suggests that stopping drinking is a simple choice. It puts the onus on the individual woman to make that choice and contributes to shame if they do not stop before they become pregnant. But in reality, there are many influences on women’s alcohol use, and real challenges to quitting before you know you are pregnant. Indeed, almost half of pregnancies are unplanned, so it is very challenging to be alcohol free before a pregnancy is confirmed.

In the case of other substances like tobacco or prescription painkillers, the public discourse extends beyond the individual user to corporate responsibilities, physicians and health authorities to provide harm reduction and treatment programs, and of governments to provide regulation and enforcement and policies that work toward social equity.

If we extend this perspective to alcohol use during pregnancy, we must speak about the responsibilities of the alcohol industry for targeting girls and women of childbearing age, and of health providers for providing comprehensive education and brief support during the preconception and prenatal periods. We must also consider the responsibilities of health services for providing integrated treatment programs for pregnant and parenting women; and of governments for ensuring gender equity and preventing violence against women.

Theoretically, stopping alcohol use in pregnancy, or ideally, before, sounds simple – just do it. But it takes a lot of individuals and sectors to do their part to make it realizable.  Simplifying it to statements like “FASD is 100% preventable” is not the best approach.

These previous blogs illustrate the full context of FASD and prevention approaches.

HOUSING IS KEY COMPONENT TO WOMEN’S RECOVERY, August 19, 2017

TARGETING STIGMA AND FASD IN MANITOBA, June 26, 2017

HEAVY DRINKING AMONG WOMEN: NORMALISING, MORALISING AND THE FACTS, Jan 24, 2017

FASD IS A PUBLIC SAFETY AND JUSTICE PRIORITY FOR ABORIGINAL GROUPS, October 23, 2016

HOW DO PARTNERS AFFECT WOMEN’S ALCOHOL USE DURING PREGNANCY? August 11, 2014

 

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 Atto2016-09-life-of-pix-free-stock-leaves-red-sky-leeroyrney 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:

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

  1. FASD Working Group. 2016. Taking Action on Fetal Alcohol Spectrum Disorder: 2016–2019: An action plan. Wellington, NZ: Ministry of Health.

 

 

 

 

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.

 

NDARC Guide

This new resource from the National Drug & Alcohol Research Centre, University of New South Wales, Australia, is designed for all primary health care professions who see women in a broad range of health care service settings during the course of their practice.

The best practices guide builds on the evidence for providing coordinated, supportive and comprehensive care to pregnant women who use substances by providing a model for reducing the harm from alcohol and substance for women and their babies. See page 12 of this guide for a clearly charted overview of how physicians and other health care practitioners can support withdrawal, do psycho-social and nutritional interventions, and address barriers to care for pregnant women.

The model acknowledges the interconnections that impact a woman’s use of substances during pregnancy – including domestic violence, mental health, smoking, and stigma – and provides a guide for identifying risk and next steps for further assessment, support and/or treatment. See page 9 for a view of how identification differs for women who are pregnant, planning a pregnancy, or not planning a pregnancy.

It also moves beyond normal referral and coordination practices by using a holistic assessment process and designating a case coordinator or clinical lead to ensure “assertive follow-up.” Assertive follow-up consists of: making sure women are supported during pregnancy and birth; keeping mothers and their babies in the hospital so that post-birth assessments for mother and child can be done and plans for support and services are in place; providing breastfeeding, safe sleeping, parenting skills and contraception support; as well as, interfacing with partners, family members, and community agencies in support of the woman and her child.  See page 16 for more discussion on assertive follow-up and pages 19-20 for “Addressing barriers to care”.

Although the extensive resources that are included in this guide are geared for practitioners in Australia, many of them provide topic-specific information that practitioners everywhere may find helpful. See pages 24-27 for website links.

For more on screening in primary care settings, see previous posts:

For more on FASD prevention in Australia, see previous posts:

 

 

 

 

Edmonton inner-city program - Aboriginal - CBC'

The Healthy, Empowered and Resilient (H.E.R.) Pregnancy Program in Edmonton, Alberta uses professional staff and peer support workers to reach at-risk pregnant and parenting women in inner city Edmonton. The program, developed by Streetworks, supports street-involved women to access healthcare services before and throughout their pregnancy and address issues such as addiction, poverty and family violence.

CBC News featured the H.E.R. Pregnancy Program last week in the article “Pregnant aboriginal women find ‘world of difference’ in Edmonton inner-city program” (July 27, 2015). Nikki Wiart interviewed staff and clients of the program and learned about the importance of outreach, peer support, and the impact of early engagement with services on pregnancy and parenting outcomes.

90% of the program’s clients are Aboriginal while 50% of the staff is Aboriginal. Morgan Chalifoux, a pregnancy support worker, with the program describes how her personal experiences as a teen mother and living on the streets can make a difference: “”Honestly, if I wasn’t aboriginal, if I didn’t have the experience, if I didn’t use when I was on the street, if I didn’t understand what it was like to have my son threatened to be taken away from me … I wouldn’t be able to have the success that I have now with the clients.”

The program uses a harm reduction approach to addressing alcohol and other substance use during pregnancy. An evaluation of the program found that:

  • 76% of 139 pregnant women who connected with the program reported substance use, typically alcohol (32%), marijuana, and other drugs
  • While connected with the program, women reported elimination of use (40%), safer use (37%), and reduction of substance use (26%) at least once during their pregnancy with the program

The Alberta government has committed to funding the program for another three years as well as developing similar programs in Red Deer and Calgary.

For more on the H.E.R. Pregnancy Program, see earlier posts:

cbc mothering project

Manito Ikwe Kagiikwe (The Mothering Project), located at Mount Carmel Clinic in Winnipeg’s North End, provides prenatal care, parenting and child development support, group programming, advocacy, and addiction support for vulnerable pregnant women and new mothers.

CBC News interviewed Stephanie Wesley and Margaret Bryans about the program earlier this week. Bryans, a nurse and program manager at Manito Ikwe Kagiikwe, discusses the successes of the program since it first opened two years ago. The article focuses on the importance of supportive relationships and the value of a ‘focus on kindness’: “Women who are pregnant, who are using drugs and alcohol are one of the most stigmatized groups in our community.” (The Mothering Project aims to break cycle of addiction, CBC News, April 28, 2015).

MC_WebBanner_Mom

The program is a wonderful example of a integrated and holistic pregnancy program for women with addiction and related concerns. The program is based on principles of harm reduction. (Learn more about harm reduction and similar programs in this booklet, Harm Reduction and Pregnancy: Community-based Approaches to Prenatal Substance Use in Western Canada).

Since the program opened two years ago, 49 women have participated. Early evaluation findings show that, at the beginning of the program, 100% of women were actively using substances, 97% had never completed a substance use treatment program and 56% did not have a prenatal health care provider. Over the course of the program, 36% stopped using alcohol and drugs, 47% reduced their use, 39% attended an addiction treatment facility and 100% accessed prenatal care. Over half of mothers have been able to take their babies home with them from the hospital. Check out the infographic below for more.

MP-INFOGRAPH-PRINT-FIN-NB_Page_1
MP-INFOGRAPH-PRINT-FIN-NB_Page_2

Final HWH conference date saver

HerWay Home in Victoria, BC is organizing a community conference and networking event for September 29, 2014.

HerWay Home is a child-focused, women-centred, family-oriented drop-in and outreach program for pregnant women and new moms with substance use challenges and their children.

When: Monday September 29, 2014

Where:  DaVinci Centre, 195 Bay Street, Victoria

Time:  09:00 – 4:00

Cost: Free to those attendees from Vancouver Island. A minimal charge of $50 to attendees from off the island.

Who should attend: HWH works with women who are pregnant or early parenting and also affected by substance use, mental health issues, violence, and trauma. This conference will be of interest to those working with women or in settings that are more focused on working with the baby (such as the NICU, foster care etc.),  along with those working on the social determinants of health such as housing, poverty, food security.

Registration information will be available in August. For more information or if you have any questions please contact HerWay Home at  Herwayhome@viha.ca

For more information about HerWay Home, see earlier posts:

Overview: Four Levels of FASD Prevention

Information Sheet: What Men Can Do To Prevent FASD

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