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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:
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
- 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 ;
- smoking currently or in the past increased the likelihood of consuming alcohol during pregnancy ;
- experiences of abuse and violence are associated with higher levels of drinking during pregnancy, 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, and;
- smoking during pregnancy was the most consistent predictor of drinking during pregnancy .
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:
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
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 . 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 .
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 . 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:
- How Do Partners Affect Women’s Alcohol Use During Pregnancy?, August 11, 2014
- How Men Can Help Prevent FASD, March 11, 2014
- Pregnant Pause Campaign for Aussie Dads, October 1, 2013
- FASD Prevention in Australia’s Ord Valley, October 13, 2011
- Getting Fathers Involved, January 4, 2011
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.
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:
- 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)
- “Women Want To Know” Campaign for Health Professionals from Australia (July 9, 2014)
- World Health Organization releases the first evidence-based global guidelines to prevent and treat substance use by pregnant women (April 18, 2014)
- Alcohol Screening, Brief Intervention and Referral: Helping Patients Reduce Alcohol-related Risks and Harms resource (December 17, 2012)
- “No Alcohol, No Risk” Film for Midwives (May 22, 2012)
- Women and alcohol resources from the American College of Obstetricians and Gynecologists (ACOG) (March 29, 2012)
- SOGC releases new clinical guidelines on alcohol use and pregnancy (August 12, 2010)
For more on FASD prevention in Australia, see previous posts:
- FASD Prevention in Australia (April 14, 2015)
- “Women Want To Know” Campaign for Health Professionals from Australia (July 9, 2014)
- Strong Spirit Strong Future campaign in Western Australia (December 19, 2013)
- Pregnant Pause Campaign for Aussie Dads(October 1, 2013)
- FASD Campaign from Kimberley and Pilbara regions of Western Australia (October 22, 2012)
- Grannies Group in South Australia addressing alcohol misuse (September 27, 2012)
- Understanding the links between FASD and early life trauma in indigenous communities in Australia (July 11, 2012)
- Alcohol Think Again Campaign in Western Australia (June 19, 2012)
- Films from the Lililwan Project: Tristan and Marulu (May 9, 2012)
- FASD Prevention in Australia’s Ord Valley (October 13, 2011)
- Yajilarra: the story of the women of Fitzroy Crossing (October 15, 2010)