Fetal Alcohol Spectrum Disorder (FASD) Prevention
Given the incredible impact of FAS/FASD on both individuals and society as a whole, the prevention of PAE and its effects is crucial. Despite ongoing health warnings, pregnant women continue to use alcohol, particularly in patterns that significantly increase the risk of prenatal injury. In 2004, the Center for Disease Control (CDC) reported that 13% of women in the US continue to use alcohol even after knowledge of their pregnancy, and 3% report binge drinking and/or drinking at levels that are known to produce adverse effects in the developing fetus (Bertrand et al., 2004).
Furthermore, approximately 55% of women of childbearing age in the US report drinking alcohol, and 12.4% report binge drinking (Rasmussen et al., 2009). As over 50% of pregnancies in the US are unplanned (Finer and Henshaw, 2006), these women are particularly high-risk. Unaware of their pregnancies, women will likely continue their alcohol use during the early stages of embryonic development. These data suggest that more effort must be made to develop effective, evidence-based prevention strategies to reduce the number of alcohol-exposed pregnancies. The first step of prevention must address the disparity between knowledge and behavior, understanding why some women – despite being aware of FAS – continue to engage in high - risk drinking behaviors.
Different levels of prevention fall along a continuum ranging from universal to selective to indicated intervention; as risk behaviors increase, prevention measures become more targeted and intensive (Barry et al., 2009).
Universal prevention attempts to promote the health of the general public, targeting all members of a population or particular group, regardless of risk. Examples of universal approaches include encouraging the abstinence from alcohol during pregnancy, raising public awareness of FASD, and creating alcohol policy and educational programs that minimize the risks of alcohol consumption during pregnancy. Methods to disseminate information include media campaigns, educational materials, and alcoholic beverage labeling. Research into the impact of the U.S. Federal Beverage Labeling Act in several different populations, including a sample of inner-city African-American pregnant women (Hankin et al., 1996 ; Hankin et al., 1993 ; Hankin, Sloan, and Sokol, 1998), has revealed an increased awareness of alcohol beverage warning labels since the law’s inception in 1989.
However, despite this increasing awareness, drinking rates have not necessarily followed suit. Within this sample, Hankin et al. (1993) observed a slight decrease in alcohol consumption, although the decline was apparent only among lighter drinkers; the warning labels did not have any significant effect on high-risk drinkers (Hankin et al., 1993). Furthermore, whilst there was a significant decrease in drinking behaviors post-label for women who had not previously given birth, no change was evident for those women who had already given birth to a child (Hankin et al., 1996). Ultimately, the observed decrease in drinking rates appears to be only short-lasting, and the effectiveness of the labels may lose their impact as women become habituated to them (Hankin, Sloan, and Sokol, 1998).
Not surprisingly, FASD is more common in communities with high prevalence rates of drinking, such as some Canadian Aboriginal communities. Strategies to reduce alcohol use during pregnancy warrant local and national attention, but two barriers have impeded the development of successful strategies in Aboriginal communities. The first is the lack of resources and research capacity in some Aboriginal communities. The second is the historically grounded cynicism about research, in particular, university-based investigators conducting research on people and their communities.
Three questions informed our writing of this article. First, can community members, who may lack formal research training related to FASD, conduct health research and develop effective community interventions themselves? (Note that we are not suggesting that all communities lack research capacity and expertise in public health interventions. Many communities do possess great capacity and sophistication. However, we wanted to implement an approach that could serve communities without adequate resources.) Second, can a collaborative research agreement be reached between academic and Aboriginal communities that provides scientific support from academics and knowledge from community members, while ensuring autonomy and community ownership of the intervention? Third, most importantly, can such partnerships initiate interventions that effectively address pressing health issues? We think this is possible, as do four Aboriginal communities participating in a project funded by the Canadian Institutes of Health Research (CIHR) - Institute of Aboriginal Peoples’ Health (IAPH).
While universal techniques have been shown to increase awareness of the risks associated with alcohol consumption during pregnancy, insufficient data are available regarding any concrete changes in drinking rates among pregnant or non- pregnant women of childbearing age (Barry et al., 2009).
Selective prevention is directed at individuals who are at greater risk than the rest of the general public of having an alcohol-exposed pregnancy due to risky behaviors, such as women of childbearing age who consume high levels of alcohol. Selective interventions are more specific when compared to universal preventions, and may include outreach to at-risk groups, alcohol screening at doctors’ offices, referral, and brief intervention strategies aimed at reducing the mother’s drinking and minimizing harm to her potential offspring.
The only sure way to prevent this problem is to abstain from alcohol during the entire length of a pregnancy.
The essential features of prevention for FAS are early recognition of risk and appropriate educational intervention.
Most women are reluctant to report the volume of alcohol they consume; moreover, if there is a positive history of alcohol consumption, the volume is usually underestimated. For these reasons, it is difficult to determine the exact amount of alcohol ingested during a woman’s pregnancy.
Pregnancy can be an opportunity to address alcohol abuse openly and to seek treatment since there are at least two lives affected.
Questions To Ask Your Doctor About Fetal Alcohol Syndrome
How does alcohol harm the fetus?
How much alcohol is harmful?
Is there a risk of birth defects?
What birth defects are possible?
How can the risks involved be minimized?
Where can I get treatment for alcohol abuse?
Indicated preventions are aimed specifically at the highest risk individuals, such as binge-drinkers, women who are alcoholics, and women who have already given birth to a child with an FASD. These approaches involve a screening process to identify such individuals and help them minimize or cease their alcohol abuse. Several brief screening instruments have been developed for use in a diversity of populations to identify problematic alcohol use in women (Bertrand et al., 2004). Studies have documented the efficacy of screening and brief interventions in reducing risky drinking behaviors and alcohol-exposed pregnancies (Floyd et al., 2009). These brief interventions include clinical advice and counseling regarding the risks of PAE, encouragement to change behaviors, and strategies and goals for reducing the use of alcohol during pregnancy.
###
Tanya T. Nguyen, Jennifer Coppens, and Edward P. Riley
Edited by Edward P. Riley, Sterling Clarren, Joanne Weinberg, and Egon Jonsson
Tanya T Nguyen practices as a Pediatrician in Alhambra, CA.
Jennifer Coppens, Medical Student, University of Alberta
Prof. Dr. Edward P. Riley San Diego State University Center for Behavioral Teratology
###
REFERENCES
- Abel, E.L. (1999) Was the fetal alcohol syndrome recognized by the Greeks and Romans? Alcohol Alcohol., 34 (6), 868 – 872.
- Adnams, C.M., Sorour, P., Kalberg, W.O., Kodituwakku, P., Perold, M.D., Kotze, A., September, S., Castle, B., Gossage, J., and May, P.A. (2007) Language and literacy outcomes from a pilot intervention study for children with fetal alcohol spectrum disorders in South Africa. Alcohol, 41 (6), 403 – 414.
- Barry, K.L., Caetano, R., Chang, G., DeJoseph, M.C., Miller, L.A., O’ Connor, M.J., Olson, H.C., Floyd, R.L., Weber, M.K., DeStefano, F., Dolina, S., Leeks, K., and National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect (March 2009) Reducing Alcohol - Exposed Pregnancies: A Report of the National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect, Centers for Disease Control and Prevention, Atlanta, GA.
- Bertrand, J. (2009) Interventions for children with fetal alcohol spectrum disorders (FASDs): overview of findings for five innovative research projects. Res. Dev. Disabil., 30 (5), 986 – 1006.