Research Update

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

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8.5 Prenatal Medical and Social Attention

Insight: Trust, Respect and Cultural Sensitivity

The foundation of all effective responses to prenatal drinking, according to the literature, is building a non-judgmental relationship based on trust, respect and cultural sensitivity. This relationship in turn needs to serve as the basis of an accurate and ongoing health and psychosocial assessment as early in the pregnancy as possible.²³⁶

When women visit a prenatal provider, they are unlikely to view substance use as an issue they are ready to work on. Consequently, the process of engagement, assessing the need for treatment and making a successful referral requires sensitivity and patience.²³⁷

For most women who are concerned about the health of their unborn child, and who are drinking harmfully, pregnancy provides a window of opportunity to address their substance use and related life issues. However, some women may not be ready or able to reduce or stop drinking or enter substance abuse treatment. In such situations, engaging and supporting women to address other important issues in their lives can improve maternal and fetal health outcomes and may subsequently lead to women reducing or stopping their use of alcohol.

Practical issues such as housing, education, job training, transportation assistance, food and income support, and help with health care and employment are often seen as higher priority needs.^238,239 It is important to note that with respect to alcohol use, some women will successfully cut back without help, others will try different ways of reducing harm to their fetus, such as switching to marijuana, not using on certain days or weeks, eating more, using prenatal vitamins and getting an increased amount of sleep.²⁴⁰ It is important to engage and support women so they can make the most informed and healthy choices for themselves and their unborn child.

Management of Withdrawal

According to the Treatment Improvement Protocol (TIP) for pregnant substance-using women prepared by the US Center for Substance Abuse Treatment, detoxification for a pregnant, alcohol-dependent woman needs to be undertaken in an inpatient setting under medical supervision that includes collaboration with a prenatal care provider.²⁴¹ That being said, physicians associated with Sheway in Vancouver, BC provide withdrawal management on an outpatient basis where inpatient stay is not realistic. At BC Women's Hospital, the Fir Square Combined Maternity Care Unit provides withdrawal management within longer term care. Mothers are stabilized so their babies have a chance to be born without withdrawal symptoms. These new mothers stay on the ward and receive life-skills and parenting training. This program is unique; availability of women-centred detoxification programs (especially medically managed services for pregnant women) is very limited in Canada, and particularly so in rural and remote regions.^242,243

Benzodiazepines and short-acting barbiturates are often used to reduce alcohol withdrawal symptoms in the general population. However, because they are teratogenic, some clinicians avoid their use with pregnant women if at all possible. Benzodiazepines are used at BC Women's Hospital in some cases as an alternative to seizures.²⁴⁴ Disulfiram (Antabuse), which is often used to support abstinence in early recovery from alcohol, is not appropriate for pregnant women because its use is associated with a number of physical anomalies in the fetus.²⁴⁵

Treatment for Women with Significant Alcohol Use Problems

The scientific literature on women's treatment is providing increasing direction to programmers and policymakers. In 2003, Ashley reviewed 38 studies of women's treatment, seven of which were randomized, and identified several components of treatment that were associated with positive outcomes: child care, prenatal services, women-only programs, supplemental services and workshops that address women focused topics, mental health care and comprehensive care. The studies found positive associations between these six components and treatment completion, length of stay, decreased use of substances, reduced mental health symptoms, improved birth outcomes, employment, self-reported health status and HIV risk reduction.²⁴⁶

There is a consensus that studies of treatment effectiveness for this population need to measure outcomes beyond abstinence from alcohol. Intermediary measures that account for decreased drinking and that assess changes in self-efficacy, stress management and decision making are viewed as critical because programs showing effect on these measures appear to have a greater and longer lasting impact on the quality of women's lives than programs that demonstrate only short-term abstinence.²⁴⁷

In the most recent review (1999) of the peer-reviewed literature on substance abuse treatment for pregnant women, Howell et al. concluded that research on treatment efficacy for pregnant women was sparse and shared the same design weaknesses as women's treatment research generally (e.g. small sample sizes, lack of adequate comparison groups). However, the literature through the 1990s does allow a conclusion that is supported by programmers: women who remain in treatment fare better than women who leave early.²⁴⁸ This was supported by the principal finding from a broad 2000 US government study (US Pregnant and Postpartum Women and Infants, PPWI), which concluded that after controlling for other possibilities, the amount of substance abuse programming (i.e. the number of contact hours with the program) received prior to delivery was the major factor in the reduction of substance use among participating women.

According to a 2004 study by Kissin et al., it is important to engage pregnant women in treatment within the first few days of contact as it is during this period that many clients drop out.²⁴⁹ Monetary incentives such as vouchers, which have been found to be effective with other populations, do not appear to increase retention and attendance among this population.^250,251 Of course, simply accessing appropriate treatment in a timely way is a large issue for pregnant women, and because readiness might be affected by waiting, this may also have an impact on retention.²⁵²

It should not be surprising, therefore, that the bulk of the research that has been conducted on treatment for pregnant women since 1999 focuses on variables that affect clients' length of stay in a program. (Within a discussion on client retention, it is again important to take a broad view of what constitutes treatment. For example, pregnant women may be too busy and tired to access intensive treatment during pregnancy, but ready to access outpatient counselling or a low-threshold service.)²⁵³

Program factors that have been shown to increase client retention include availability of child care, single-gender programming, transportation, case management,²⁵⁴ supportive housing and programs that are well connected with mental health services and family service providers.²⁵⁵ Client factors that have been associated with program completion include having previous experience with treatment (personally or through partner's ²⁵⁶ chance of program completion).²⁵⁷ Among women being served by the Toronto community agency, Breaking the Cycle, the client factors most associated with leaving treatment early were low education and a primary addiction to crack or cocaine.²⁵⁸

The fact that previous experience with the treatment system is linked to longer stays suggests that women who have not been in treatment may be fearful of child custody issues, labelling issues and may fear the unknown, and that providers need to promote a better understanding of treatment. Alternatively, Knight et al. found that women with a criminal justice history and deviant friends were more likely to leave early, in spite of the legal pressure to remain in treatment that some experience.²⁵⁹

Health Canada's 2001 report Best Practices: Fetal Alcohol Syndrome and the Effects of Other Substance Use During Pregnancy cites findings from the PPWI projects and other US government granting programs that give guidance on successfully reaching pregnant substance users and retaining them in care. These themes continue to be supported by US and Canadian studies and experience.

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