Research Update

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

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Insight: Respectful Service Required

With recognition that shame, guilt and mistrust of the systems scrutinizing women who use alcohol during pregnancy have been identified as barriers in accessing care,²⁶⁰ programs have shifted toward an empowering, strengths-based and women-centred approach. Central to this approach is an openness for allowing women to set goals for improving their health that may not give immediate priority to substance use issues, and when they do, accommodating goals of reduced use rather than immediate abstinence.²⁶¹ Breaking the Cycle in Toronto,^xxvii Food for Thought in Saskatoon,^xxviii the various First Steps programs in Alberta, such as the Catholic Social Services program in Edmonton^xxix and Sheway in Vancouver,^xxx are Canadian programs that exemplify this approach. These programs employ a non-judgmental harm reduction approach in their work with substance-using pregnant women experiencing very significant challenges.

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8.6 Providing Comprehensive and Practical Care

Of the various services needed by women who consume alcohol while pregnant, treatment for substance use problems is often seen as having the most formidable barriers, so formal addiction treatment programs often engage women through other avenues. This has the effect of reducing related harms to the mother and unborn child while increasing the likelihood that formal substance abuse treatment will be considered. Noting this, programs strive to combine alcohol and drug treatment with other services, such as prenatal care, other medical care, parenting education, transportation to appointments, family-planning services, assistance to access child care, nutritional support, advocacy on housing needs, and counselling on violence and relationship issues.^262-269 Women often indicate that child care is the most crucial element in a comprehensive program, and there is strong evidence that women who live with their children during treatment remain in treatment longer than women who do not.²⁷⁰

Women who participate in these programs have been shown to lower their stress and stabilize their family situations,²⁷¹ while their children show significantly lower infant mortality, higher birthweight and are more likely to be full-term babies.²⁷² In some cases, comprehensive programming has been organized into a “one-stop” multidisciplinary clinic setting, such as that provided by Breaking the Cycle (Toronto) and Sheway (Vancouver) programs. Conversely, some programs for pregnant women provide far fewer services and seem to focus almost exclusively on pregnancy in much the same way that traditional substance abuse programs treat “the addiction.” These programs fail to provide the vast array of services necessary for recovery. Not surprisingly, although such programs demonstrate improved birth outcomes, overall success rates appear to be lower and less comprehensive.²⁷³

Interagency Collaboration and Coordination of Services

Given the range of health, social and practical services important to a comprehensive service, coordination and collaboration between services is crucial. The collaborative linkages established with a variety of community-based medical, mental health and social services; literacy programs; vocational training and job placement; children's assessment services; and family court and child welfare systems were identified as a major strength of 35 programs supported by the US government's Pregnant and Postpartum Women's (PPW) programs. Perhaps the most critical area of collaboration is between the child welfare and substance abuse treatment domains.²⁷⁴

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Insight: Coordinating Services in Smaller Communities

The Maxine Wright Centre in Surrey, BC, is an example of a Canadian program that has been established with a clear aim of coordinating services for pregnant women with substance use issues. The goal of its high-risk pregnancy and early parenting program is to coordinate and provide pre- and postnatal care to women who are least likely to access traditional medical resources and to coordinate and provide services to their young children. The program has been developed on the basis of a review of the literature and community consultations and is currently under evaluation.²⁷⁵ It is in this way that communities that do not necessarily have the numbers to support a one-stop centre can provide comprehensive care.

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A Broad and Flexible Continuum of Substance Abuse Services

To address the considerable challenges in supporting pregnant women to enter, re-enter and complete substance abuse treatment, a broad menu of services – including outreach, case management, pretreatment programming, harm reduction programming, medical detoxification, short-term intensive programs (day and residential), as well as sober housing and aftercare – is advocated.^276,277 Further, flexibility in providing access and in accommodating absences while in treatment has been found to be critical for enhancing retention of the pregnant and parenting women receiving care. The process through treatment for pregnant and parenting women is not necessarily orderly, but more often takes a complicated cycle of entering treatment, trying different types of treatment, relapse, reunifying with children, completing treatment and maintaining sobriety. Support in the postnatal period for new mothers and their infants can be effective in reaching mothers with substance use problems to support ongoing change and self-efficacy.

Case Coordination or Management

Case coordination, from a broad, client-centred approach, is repeatedly described as a key component of an alcohol and drug system of care responsive to the needs of pregnant women. Case management services that include home visits, telephone counselling, transportation and advocacy with other professionals by members of a multidisciplinary team significantly contribute to retention in treatment.²⁷⁸

A well-designed evaluation of the Seattle Birth to Three Program illustrates the value of an intensive case coordination approach.²⁷⁹ Using a random control study design, the program studied the effectiveness of intensive, long-term case coordination using para-professional “advocates.” The advocates did not provide direct services, such as substance abuse treatment or child care, but facilitated the women's connection with these services in the community through regular and as-needed home visits and active contact with the extended family. The program also gave attention to family planning as an option for preventing FASD. This powerful intervention supported the women in making and sustaining positive lifestyle changes, with half of them entering treatment and three-quarters following a reliable familyplanning method upon completion of the three-year intervention.²⁸⁰

In a follow-up of participants two years after completion of the intervention, investigators found that these seriously marginized women were generally managing to sustain their changes, even though the challenges they faced were daunting.²⁸¹ Because this postprogram study did not use a comparison group, it is not so clear that the intervention is responsible for observed changes; however, given the massive challenge involved with pulling oneself out of the intergenerational cycle of deprivation that many of the women faced, these findings are nevertheless very important. Manitoba's Stop FASxxxi programs and the First Steps programs in Alberta^xxxii are replicates of this model.

Attention to Family Issues

Programs that integrate women, children and partners into their care have often been found to improve treatment outcomes for women in the perinatal period. An almost universal finding is that women are often unwilling or unable to separate themselves from their caregiver role to attend to their treatment needs. Many programs have found that even when partner relationships are in turmoil, a primary task of this period is decision making around disconnecting or reuniting, and program support through this is important.²⁸² There is a continuing need for attention to child care and mothering issues in the formal addiction treatment sector.

Continuing Care/Aftercare

The literature on continuing care and aftercare for women, particularly pregnant women, continues to be limited. However, aftercare makes intuitive sense, considering the vast number of issues and lifestyle changes that women typically need to work through following a period of treatment. These can include development of new social support networks, dealing with new roles in the family, relationship issues, learning to anticipate events that precipitate drinking, dealing with new emotions and learning to trust others. Continuing care programs can take various forms, including group sessions, individual counselling and phone support. A BC Women's Hospital aftercare pilot project that employed these methods and focused on smoking cessation, trauma counselling, vocational training and parenting skills found that participants valued these services and improved their health in a number of ways.²⁸³

Use of Motivational Counselling Approaches

Motivational approaches, which were shown to be effective as brief interventions with nondependent women in the previous section, can be effective with dependent women in the context of more extensive interventions. Community parent, child and family agencies often see women who are not considering changes in their substance use and find approaches based on motivational principles to be useful.

The use of motivational principles to help women with significant substance use issues has been described in a Canadian training manual for providers working with pregnant women who use alcohol that was prepared by AWARE (Action on Women's Addictions – Research and Education),^xxxiii a women's health research program, and Breaking the Cycle,^xxxiv a one-stop service for high-risk mothers and their young children.²⁸⁴ Using motivational counselling in the context of stages of change theory (the Transtheoretical Model of Behaviour Change), agencies can work with a woman to increase her “readiness” to address substance use. This means working with a woman to help her move from the point of not considering changes in this area of her life (precontemplation) to the point of considering possibilities (contemplation), preparing to act (preparation), ultimately acting on (action), and ideally, sustaining the changes (maintenance).^285,286 The process rests on the assumption that everyone has strengths that can be brought out to address problems and that a person's motivation to do so is not fixed – it can shift with events (e.g. pregnancy or an accident) or through contact with another person. This is not usually a short process for women with significant alcohol use issues that co-exist with other serious issues.

Although a motivational intervention in a community agency may aim to bring a person to the point where she will accept a referral to a formal treatment service, in many cases, treatment is occurring in these community agencies – that is, counsellors are supporting women through all these stages of change and helping her to address relapses that are part of the process of change. Motivational approaches are consistent with women-centred approaches that foster autonomy and self-efficacy among pregnant women.²⁸⁷

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xxvii. www.breakingthecycle.ca/

xxviii. www.phac-aspc.gc.ca/dca-dea/publications/pdf/woodsworth_e.pdf

xxix. www.child.gov.ab.ca/whatwedo/fas/page.cfm?pg=FASD%20Demonstration%20Projects#firststeps

xxx. http://www.vch.ca/women/sheway.htm

xxxi. www.gov.mb.ca/healthychild/fas/stopfas.html

xxxii. www.child.gov.ab.ca/whatwedo/fas/page.cfm?pg=FASD%20Demonstration%20Projects#first_steps

xxxiii. www.aware.on.ca

xxxiv. www.breakingthecycle.ca

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