Women, Alcohol, Pregnancy, FASD Prevention Nancy Poole, BCCEWH and CanFASD Research Network

1. Women, Alcohol, Pregnancy, FASD PreventionNancy Poole, BCCEWH and CanFASD Research Network NANCY POOLE Director , BC Centre of Excellence for Women’s Health CPHA June 2014

2. Issues

3. Issue: Scope of FASD prevention is expanding beyond alcohol use GENETICS AGE OTHER SUBSTANCE USE NUTRITIONAL STATUS ACCESS TO PRENATAL CARE STIGMA RACIAL DISCRIMINATION PAST AND CURRENT EXPERIENCES OF VIOLENCE AND ABUSE ACCESS TO CONTRACEPTION CHILD WELFARE AND MOTHERING POLICIES ........ RISK OF CHILD BEING BORN WITH FASD = + + ALCOHOL PREGNANCY

4. Issue: Greater understanding of diversity of women at risk • Many diverse groups of women are more likely to consume alcohol during pregnancy, including women who: • are older (over 30) • have high income or who are unemployed or living in poverty • are in an abusive relationship • use other substances • are depressed • are coping with trauma • have a partner who drinks heavily • are coping with the intergenerational effects of colonization • (Skagerstróm et al, 2011; Niccols et al, 2009; Best Start, 2003; Bakhireva et al, 2011) ‘Middle class’ mothers as an overlooked risk group?

5. The story of the highest risk mothers • Study of Birth Mothers of 160 children with FAS • Of the 80 interviewed: • 100% seriously sexually, physically or emotionally abused • 80% had a major mental illness • 80% lived with men who did not want them to quit drinking Astley, S. J., Bailey, D., Talbot, C., & Clarren, S. K. (2000). Fetal Alcohol Syndrome (FAS) Primary Prevention through FASD Diagnosis II: A comprehensive profile of 80 birth mothers of children with FAS. Alcohol and Alcoholism, 35(5), 509-519.

6. Why do women drink alcohol during pregnancy? • Women are unaware they are pregnant. • Women are unaware of the extent of damage alcohol can cause the fetus. • Women underestimate the harms alcohol consumption can cause because they know other women who drank during pregnancy and their children appear healthy. • Alcohol use is the norm in their social group and abstaining may therefore be difficult. • Women may be using alcohol to cope with difficult life situations such as violence, depression, poverty, or isolation. • Women may struggle with alcohol addiction. (Cismaru et al., 2010) Coalescing on Women and Substance Use | www.coalescing-vc.org

7. Women report that guilt, shame and fears of losing their children to child welfare authorities prevent them from getting the help they need with alcohol problems Physicians report that they don’t feel fully prepared to discuss substance use with women Issue: Barriers to discussing alcohol use with pregnant women

8. Unless proactive, problem alcohol use in women is often not recognized or treated Often health care providers use confrontational, proscriptive or substance-focused approaches, which can be ineffective in supporting paced and achievable change in substance use by women Issue:Lack of recognition and tailored support The Risk Drinking Project was a national government initiative carried out from 2004 to 2010 in Sweden. The proportion of midwives who considered themselves to have very good or good knowledge in identifying patients with risky alcohol consumption increased from 72 to 92 per cent between 2006 and 2009.

9. Issue: Light drinking in pregnancy Evidence is inconsistent at low-moderate levels of consumption. Some studies suggest NO EFFECT of light-moderate drinking during pregnancy Recent examples: Kelly et al (2008, 2012, 2013) - No increased risk of clinically relevant behavioural difficulties, cognitive deficits at age 3, 5, and 7 (N=10,534 - 12,495); differences in scores between boys and girls Humphriss et al (2013) - No effect of moderate (3-7 glasses/week) maternal alcohol consumption on balance at age 10; Some studies show a ‘J’ or ‘U’ shaped curve suggesting a protective effect from light drinking

10. Issue: Light drinking in pregnancy Evidence is inconsistent at low-moderate levels of consumption. Some studies suggest ADVERSE EFFECTS of light-moderate drinking during pregnancy Recent examples: Andersen et al (2012) - Low to moderate consumption of alcohol increased risk of spontaneous abortion substantially in first trimester (N= 92 719) Feldman et al (2012) - Increased risks for physical features of FAS and growth deficiencies (reduced birth length and weight); dose-related effects, no evidence of safe threshold at lower amounts of alcohol use Nykjaer et al (2014) Even at 2 units per wk or less, low birth weight and preterm birth Studies define ‘light’ drinking differently which contributes to confusion.

11. Issue: Messaging around ‘light drinking’ • While the risk from "light" consumption during pregnancy appears very low, there is no known threshold of alcohol use in pregnancy that has been definitively proven to be safe. • Individual-level factors such as nutrition, genetics, and other substance use can interact to affect outcomes. • Potential for misunderstanding drink sizes and actual alcohol content of various types of drinks • Compelling evidence from research on animals that even low doses of alcohol at any time during pregnancy can affect fetus “No safe time. No safe amount. No safe kind.” Coalescing on Women and Substance Use | www.coalescing-vc.org

12. Recent research on messaging Discussing ambiguity with women - Helpful or not? Public health guidelines: "The safest choice is to not drink at all while pregnant, planning to become pregnant or before breastfeeding“ Importance of being honest and factual about the limits of research on alcohol during pregnancy suggested by some studies “Credibility … was enhanced by acknowledging uncertainty about the risk to the fetus with low to moderate alcohol exposure. Rather than undermine an abstinence-based message, this information served as a clear rationale for the recommendation. An honest and scientific framing of the message and delivery by an expert source were also shown to minimize counterargument and strengthen the message’s persuasiveness.” (France et al., 2013, p.8)

13. Promising Developments

14. We have evidence for effectiveness of strategies at 4 levels LEVEL 2 Discussion of alcohol use and related risks with all women of childbearing years and their support networks • Today - will focus briefly on promising developments in: • Level 1 • Awareness and health promotion • Level 2 • Brief Interventions • Dual-focused Interventions (Alcohol + Contraception) • Preconception Interventions LEVEL 3 Specialized, holistic support of pregnant women with alcohol and other health/ social problems LEVEL 1 Broad awareness building and health promotion efforts SUPPORTIVE ALCOHOL POLICY LEVEL 4 Support for new mothers and for child development and assessment Strategies that involve women, support networks, communities, service providers, health system planners, governments

15. Current Awareness Building Examples: • Development of health education materials (pamphlets, posters) • Awareness campaigns • Low risk drinking guidelines • Materials for facilitators of girls’ empowerment groups http://www.ccsa.ca http://www.womenspopulationhealth.ca/womenandalcohol www.bcliquorstores.com http://girlsactionfoundation.ca http://www.skprevention.ca/

16. There is evidence for a wide range of tools and interventions related to identification and brief support • Drink size and “alcohol literacy” • Routine screening • Screening for polydrug use (e.g., alcohol and tobacco) • Formal tools: CAGE, AUDIT, T-ACE, TWEAK and new tools such as 3 questions (Substance Use Risk Profile), indirect screening, and questionnaire based counselling at maternity care centres • Web- and computer-based interventions, telephone screening • Medical school training and continuing education

17. Evidence for collaborative preconception approaches • Project CHOICES • Multi-site RCT - CHOICES intervention (motivational plus assessment feedback counseling intervention) vs. informational brochure • Reductions in AEP risk were significantly more likely among participants who received CHOICES than participants who received informational brochures. • The absolute risk reduction (the decrease in risk from baseline to follow-up of the intervention condition relative to a comparison condition) was 18% (Floyd et al., 2007; Ingersoll, Floyd, Sobell, Velasquez, & Project CHOICES Intervention Research Group, 2003) • Project BALANCE • RCT - Tested among college women ages 18–25 at risk for AEP by comparing one 60-minute session (BALANCE) to an informational brochure condition • At a 4-month follow-up, 80% of participants who received BALANCE reported no past month AEP risk, compared to 65% of participants who received the informational brochure, representing a 15% absolute risk difference between conditions.(Ceperich & Ingersoll, 2011; Ingersoll, Ceperich, Nettleman, Karanda, Brocksen, & Johnson, 2005) Project CHOICES Facilitator Guide(via www.cdc.gov)

18. Need for support on alcohol beyond pregnancy, to support women’s health, and their role as mothers Report from SAMHSA 2009 • Rapid resumption of substance use noted in first 3 months postpartum

19. Guidelines for brief intervention are in place Health professionals who routinely provide healthcare to women of childbearing age are uniquely positioned to deliver important information about the health risks around the use of alcohol, tobacco and other drugs. • In general, research evidence supports screening and brief interventions for alcohol misuse as efficacious and cost-effective in a variety of settings.

20. Avoiding ‘gender-exploitive’ approaches

21. Culturally safe approaches are being identified - perspectives of women with alcohol and drug problems • In a recent study, Aboriginal women participating in treatment identified the RECLAIM principles as important for treatment providers to understand and apply when supporting Aboriginal women’s healing from illicit drug abuse. From Stillettos to Mocassins http://www.youtube.com/watch?v=1QRb8wA2iHs Colleen Anne Dell, Research Chair in Substance Abuse, University of Saskatchewan www.addictionresearchchair.ca

22. Wide range of people are interested in having “empowering conversations” Transition House Workers FASD Key Workers Youth Support Workers Addictions Counselors Doulas Family Support Workers Supporting women in childbearing years around alcohol and related concerns Aboriginal Service Providers Midwives Acute Care Nurses Nutritionists Pregnancy Outreach Workers Mental Health Service Providers Dental Hygienists Physicians Public Health Nurses Early Childhood Development Program Providers Tobacco Reduction Coordinators Social Workers Peer Support/Mentors

23. SUMMARY Putting our efforts into a range of alcohol policy, health promotion and prevention efforts seems wise: • awareness building and community development • brief alcohol intervention with all women • holistic support with pregnant women with alcohol and related health and social concerns • support for new mothers and children, and • community alcohol policy Four Levels of FASD Prevention(Poole, 2008)

24. Selected Publications from the CanFASD Prevention Network Action Team

25. Contact • BC Centre of Excellence for Women's Health • www.bccewh.bc.ca • Coalescing on Women and Substance Use • www.coalescing-vc.org • Canada FASD Research Network • www.canfasd.ca • Girls, Women, Alcohol, and Pregnancy Blog • http://fasdprevention.wordpress.com • Our blog is a resource for learning about specific prevention topics as well as prevention work around the world, • 68 posts were made over the 2013 year • The blog was viewed about 38,000times in 2013, on average 3000 times per month, and on average 100 times per day • by people in 161 countries