«No known safe amount or safe time to drink alcohol during pregnancy»
Fetal Alcohol Spectrum Disorder (FASD) is the term used to describe the range of harms that can result from prenatal alcohol exposure. FASD is often found in combination with a range of other health and social problems faced by pregnant women. These harms can include vision and hearing problems, as well as slow growth and brain damage that result in lifelong problems with attention, memory, reasoning and judgment. Fetal Alcohol Spectrum Disorder (FASD) is a leading known cause of developmental disability in Canada. As important as this issue is, effective prevention remains a key challenge.
This resource describes what has been learned about prevention of FASD in the course of implementation of health promotion and prevention strategies across Canada. It outlines a four-part framework for FASD prevention and promotion of women's and children's health which has been identified by a group of Canadian experts as they have developed and evaluated FASD prevention initiatives at the community, provincial/territorial and national levels. This prevention resource reflects a pan-Canadian vision for both preventing FASD and improving the outcomes for those who are already living with it.
This is a practical resource, created to assist those who are planning or expanding FASD prevention programming designed to reach and support women of childbearing years. It has as a foundation the practice-based wisdom of program providers in Canada, and at the same time, it is important to note that the programs listed here are examples only, and do not form an exhaustive list of the FASD prevention programming in Canada.
FASD prevention work is complex; it involves much more than providing information about the risks of alcohol use in pregnancy. Preventing risky alcohol use by pregnant women (and mothers before and after pregnancy) does not take place at only one point in time, nor does it occur through a single interaction with one care provider.
Over the past decade in Canada, health promotion and prevention specialists have been learning about how to prevent FASD using multi-sectoral, holistic approaches. Beyond advice to not drink while pregnant, these newer, holistic approaches have demonstrated that helping women plan their pregnancies, obtain prenatal care, improve their nutrition, reduce stress in pregnancy and heal from root causes of addiction such as experience of violence - all contribute to improving women's health and reducing the risk of having a child affected by FASD.
Canadian prevention specialists have identified four mutually reinforcing prevention approaches as effective in delivering FASD prevention. The four levels of prevention span general and specific practices that assist women to improve their health and the health of their babies, with support from family, support networks, services and community. They include:
This first level of prevention is directed broadly to all sectors of society, including girls and women of childbearing years. It is designed to:
Pamphlets, prevention campaigns, warning signs in bars, and other forms of public education are examples of how people have brought awareness raising goals into action. This level of prevention is a foundation for the other three levels of prevention, reaching the largest numbers of people, and sparking awareness and reduction in stigma and blame.
Community development strategies are also a key component of Level 1 FASD prevention. People are getting together to bring awareness to women's substance use and related health and social issues, and to link those working with children, youth and adults who are affected by FASD. It is about connecting the people in a position to contribute to awareness and action and involving them in working together on community and system-level changes.
For some women, this type of information is sufficient to create or maintain positive changes in their health. This level of prevention has the potential to provide good information to everyone who needs it to make decisions about alcohol use in pregnancy. This level of prevention also serves to connect people so they can work together to make the service system more welcoming to women with substance use problems and to work on a range of community-level solutions that support the health of women and children.
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«This is our baby»
Community development strategies
First Canadian statement on prevention of FASD
This level of prevention is important for women who lack information, have misconceptions, or need to know how to access services related to prenatal alcohol use. If awareness is already high, Level 1 prevention strategies may be a lower priority. Where increased awareness is needed, messages directed to women in general may not be helpful to some subgroups, and tailored messaging may be required for girls and women based on age, income, ethnicity and other differences.
There is value in having messages in health clinics where most women access prenatal care, but this information is also needed at community-based programs, social service agencies and other points of access for women. People don't change because they see a poster, they change because they see a poster in the context of a place they trust, and then a conversation starts, and then you go from there…
The second level of prevention involves collaborative discussion of alcohol use and related risks with all women of childbearing years, as well as with their support networks. It also involves discussion of ways of coping without alcohol, prenatal supports available, and pregnancy planning.
Physicians have long been recognized as important providers of information and support. However, many other service providers who come into contact with girls and women in many settings have also been found to be helpful when they provide information and brief support. In fact, Level 2 FASD prevention involves system-wide commitment on the part of all service providers working with women to engage in informed and respectful discussion of alcohol and other substance use.
A 2002 survey of physicians and midwives in Canada  found that while 94% knew about FASD, less than half of care providers consistently discussed smoking, alcohol use or addiction with women of childbearing age. Further, only 54% felt prepared to care for pregnant women who had substance use problems. Assisting service providers who are willing to develop their competence in discussing alcohol use and related risks with all women of childbearing years is a critical component of FASD prevention.
There is strong evidence for the effectiveness of brief collaborative, motivational interviewing approaches  for reducing the risk of women having an alcohol exposed pregnancy. In fact, a service provider who takes an empathetic, collaborative approach is one of the strongest predictors of whether a woman will be able to change .
When this level of prevention is in place, the risks of drinking in pregnancy are discussed with all girls and women, and a range of options and resources for having healthy pregnancies are provided to enhance women's decision making and access to supports where needed. Girls and women who are using alcohol in risky ways are helped to reduce or stop their alcohol use during pregnancy, and those with substantial alcohol and other health problems are linked to the comprehensive care described in Level 3 prevention.
Multi-sectoral training of providers
Training for physicians and others on substance use and pregnancy
Online learning module for physicians
Information and support line for women and professionals
Community-based services that discuss substance use with pregnant women
Aboriginal service providers
The HELP Guide for Professionals
SMART Guide - To order contact email@example.com
Trainer's Guide to Motivational Interviewing
This level of prevention is critical to girls and women having the information and support they need to have a healthy pregnancy and reduce the risk of having a child with FASD. In the past, not all girls and women have been asked about their alcohol use. Furthermore, the experience of stigmatization, or even a perception or fear of judgment on the part of service providers is a barrier to girls and women seeking services. Some subgroups of women, such as middle class women who are birth mothers of children with FASD, have reported that they were not given the information they needed. It is therefore important to ask all girls and women of childbearing years what they know about the risk of alcohol use in pregnancy and provide information and support tailored to their need.
Discussion and provision of brief support are more likely to be done by primary health and other service providers than by specialized addictions workers. That is why training for every service provider is important, so they feel confident, committed and competent in discussing substance use.
The third level of prevention involves the provision of respectful and holistic care and treatment for girls and women who are using alcohol during pregnancy and have related health, social and financial concerns.
Level 3 - FASD prevention is delivered through specialized, holistic support of pregnant women with substance use problems and other health and social problems. In urban settings this support is often provided through a combination of outreach and
«one stop» drop-in services, and in smaller settings through a network of community-based services. Across the constellation of services provided in rural and urban settings, women can be provided with support on a range of factors which influence their alcohol use.
A critical aspect of this level of FASD prevention is overcoming pervasive barriers to access care. A culturally relevant, non-judgmental approach, paired with accessible and comprehensive services helps reduce barriers to care. Services that operate from a harm reduction perspective are effective in supporting improvement in women's health by their recognition and acceptance of the pace and types of change women are able to make.
In addition, mother-centred addictions treatment needs to be readily available to pregnant women and mothers with substance use problems. While all addictions treatment services provide priority access to pregnant women, often the programming has not been tailored to their needs. For example the programming may require daily time commitments that do not allow enough time for rest and prenatal appointments. Promising outreach initiatives and community-based, day and residential programming, that are more supportive of the needs of pregnant women and new mothers are being developed.
Level 3 FASD prevention work supports women's connection to the services they need, and can be a first positive experience with health and other systems of care by women with substance use problems, who have been disempowered by societal disapproval of substance use by women, and/or by their social, geographical or economic status. Evaluations of Level 3 prevention services show women who access these services benefit in physical health improvement, nutritional status, access to stable housing, connection to substance use treatment, parenting capacity and ability to retain custody of their children and in many other ways [4-6]. In the context of Level 3 prevention services, women may be assisted with healing from current or past experiences of violence in their lives. The support women receive in Level 3 prevention services also has positive impacts on the birth weights and health of their babies, including prevention of FASD.
At this level of FASD prevention it is especially important that women's fears about apprehension of their children are addressed. Women need to be confident that a range of supports will be
«wrapped around» the mother-baby pair, to help mothers create safety and health for themselves and their children. A welcoming, health-oriented approach, taken by linked providers who have specialties in women's health, prenatal, addictions, maternity care, housing, education and child health and welfare can achieve this end.
Evaluations and research in this area highlight the importance of addressing a woman's immediate pragmatic needs, and the determinants underlying her alcohol and other health concerns, not merely focusing on her substance use.
This level of FASD prevention involves supporting new mothers to maintain healthy changes in their alcohol use and related health and social issues that they have been able to make during pregnancy. It also involves supporting new mothers who were not able to make changes in their substance use during pregnancy, to continue to assist them to improve their health and social support, as well as the health of their children. It may also involve early intervention services for their children.
Level 4 - FASD prevention comprises ongoing holistic, non-judgmental health care, social support, advocacy and peer support - all designed to make it safe to be a mother who has, or has had, alcohol problems. It also supports women who do not have alcohol problems who wish to begin drinking moderately again, to arrange their breastfeeding schedule to reduce the risk of alcohol exposure through breast milk.
Previous conceptualizations of prevention of FASD often did not include provision of support in the postpartum period. However, increasingly, assistance is seen as important both for women who have been able to stop using in pregnancy to prevent relapse, and for women who have continued to struggle with alcohol problems and/or who are birth mothers of children with FASD. Level 4 FASD prevention aims to provide postpartum support for mothers to continue to improve their health, as well as the health of their children. It can also include programming for mothers such as traditional parenting programs.
For mothers who have been able to reduce their alcohol use during pregnancy, help with continuing to manage their use and access related supports which help them reduce risk can be vital.
For mothers in recovery - As recovery from substance use problems and addiction is a process, it is crucial to help new mothers with addiction problems who have been able to achieve abstinence goals during pregnancy, to continue with their recovery .
For mothers with ongoing alcohol problems and/or with children affected by FASD - Comprehensive support provided in the 3 years postpartum has been demonstrated to help mothers who are still facing alcohol problems and birth mothers of children with FASD to make changes that improve their health, increase their ability to parent, and reduce the risk of having another child affected .
Community-based mentoring programs in Aboriginal communities
Community-based mentoring programs in Non Aboriginal communities
Community Action Programs for Children (CAPC) programs such as
Postpartum discussion approach - OAR (Own Act and Reflect)
Traditional parenting programming
Summary of Research
In primary health care settings, and in other community-based services and advocacy programs, it will be important to continue to find effective ways to support mothers and their families - both those mothers who were able to stop drinking in pregnancy and those who were not.
Early support that links children with prenatal alcohol exposure to the interventions and supports they may require, is important. Most mothers are eager to do all they can to assist their children in accessing these supports. Through this process of helping their children, mothers can be assisted in resolving feelings of guilt and self-blame regarding the effects of their alcohol use in pregnancy, and supported to address their substance use and related issues, and prevent the births of subsequent children who may be affected.
Canadian service providers and health system planners are making tremendous strides in conceptualizing and implementing comprehensive FASD prevention strategies. Utilizing this four level framework for prevention has helped to effectively tailor our work to reach women with differing needs for information and support. It has also allowed for the engagement a wide range of advocates, providers and communities in FASD prevention work.
More advocates, services and communities are invited to take up this work. It is hoped that more research will inform this work and that evaluation of the work currently being undertaken will be made possible. May the framework, ideas, practice examples and resources described in this booklet be helpful in inspiring and linking those interested in this work.
The author wishes to extend sincere appreciation to: