Research Update

Alcohol Use and Pregnancy: An Important Canadian Public Health and Social Issue

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8 Indicated Prevention of Prenatal Alcohol Use Problems

What the Studies Say Indicated prevention measures attempt to prevent or minimize harm among pregnant women with significant substance use issues. Women with these issues often have a history of physical or sexual abuse and experience concurrent mental health problems as well. Consequently, programs that work best are those that provide respectful, flexible care, offering support in a number of life areas, including access to child care. Motivational counselling and intensive case coordination are two modalities that have shown promise in supporting high-risk women in making healthy decisions concerning contraception and/or their use of alcohol.

Indicated prevention measures are directed at women who are at high risk for having a child affected by FASD. This includes alcohol-dependent women of childbearing age, women who have consumed alcohol during previous pregnancies, and pregnant women who have delivered an infant with FASD and continue to use alcohol.¹⁹⁹ Women who themselves are affected by FASD may also be at high risk of having a child with FASD.²⁰⁰ This level of prevention includes treatment for alcohol dependence among pregnant women or women who are likely to become pregnant, support with the many other issues they typically face, and measures to encourage the prevention of pregnancy.^201,202 Reducing harms arising from continued use by reducing higher risk use, promoting the overall health of the mother and increasing her capacity to care for her children effectively are also legitimate aims.²⁰³ This section reviews research in the following related areas:

• identifying women who benefit from indicated prevention measures
• barriers to identifying pregnant women with significant substance use issues
• outreach
• targeted indicated prevention messaging
• prenatal medical and social attention
• management of withdrawal
• treatment for women with significant substance use problems
• treatment for pregnant women with significant substance use problems
• respectful service philosophy
• providing comprehensive and practical care
• interagency collaboration and coordination of services
• broad and flexible continuum of substance abuse services
• case management
• attention to family issues
• continuing or aftercare
• use of motivational counselling approaches
• Canadian models
• prevention through diagnosis
• culturally appropriate treatment for Aboriginal women
• cost-effectiveness of treatment

8.1 Identifying Women Who Benefit from Indicated Prevention Measures

Women who have been unable to stop consuming alcohol while pregnant on their own or through a brief intervention may benefit from having access to supportive and intensive intervention. Although there is some indication that Canadian Aboriginal women may differ in this respect,²⁰⁴ when women do seek help, those with drinking problems tend to seek out health and mental health services rather than substance abuse services.²⁰⁵ This is likely due, in part, to the added stigma experienced by women with substance use problems. However, when asked about using substance abuse treatment services, women participating in qualitative research in British Columbia also cited “not knowing what treatment was available” and “not knowing what treatment would be like” as barriers.²⁰⁶

Women in this target population experience a range of co-existing risk factors. Typically, they have not fared well with respect to factors that are understood to fundamentally influence the health of individuals and populations, particularly education, employment and adequate income.²⁰⁷ Moreover, a high proportion of these women have experienced physical and sexual violence in their lives. For some, violence starts during pregnancy, for others its frequency and severity increases during pregnancy.²⁰⁸ For many Aboriginal mothers, these circumstances are exacerbated by the intergenerational impacts of the residential school system and other elements of colonial oppression.²⁰⁹ Depression and anxiety can stem from violence and other seemingly intractable difficulties, but are worsened among women with little or poor social support. Consequently, assessment should include an exploration of mental health status, domestic violence issues and other frequently occurring co-existing risk factors.²¹⁰

Because age and number of previous children appear to be large factors in determining the likelihood of a FASD-affected child occurring through a mother's use of alcohol, some suggest that the optimal time to identify and intervene is after the first pregnancy.²¹¹ With everything else being equal, mothers who are older, have already had a child and continue to drink in pregnancy appear to be at higher risk of having a child with FASD than a younger woman without children. Women in this situation may point to their apparently healthy child as evidence that their drinking is not a problem and see standard prevention messages as not credible.²¹² Nevertheless, a pregnancy will often stimulate an interest in health-promoting behaviour that a supportive, non-judgmental service provider can effectively use as a point of engagement.²¹³

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