Fetal Alcohol Syndrome Diagnosis, Epidemiology, Prevention, and Treatment (1996) / Chapter Skim
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7 Prevention of Fetal Alcohol Syndrome
7 Prevention of Fetal Alcohol Syndrome
Pages 112-153
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From page 112... ...
Many people who abuse alcohol do not get the help they need, either because they do not have access to the health care or social services system or because some health care or social services professionals are uncomfortable talking with patients about substance abuse problems. Finally, the use and abuse of alcohol have long been centered in emotional and moral debate.
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From page 113... ...
As this chapter points out, controlled research on the prevention of FAS is scarce. Also, as discussed in greater detail in a subsequent section, it is not clear if these programs are available to, used by, or effective for those women who abuse alcohol in a manner that puts their fetus at risk for FAS, ARBD, or ARND.
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From page 114... ...
Definitions Universal prevention attempts to promote the health and well-being of all individuals in society or of a particular community. Universal prevention interventions are those targeted to the general public to or an entire population group
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From page 115... ...
That is, although prevention interventions are generally thought of as stopping short of treatment interventions, when thinking about a comprehensive prevention program for FAS, ARBD, and ARND, it is clear that treatment of alcohol problems in pregnant women (and their partners) is an appropriate indicated prevention intervention for the fetus being carried by the woman, as well as for future pregnancies.
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From page 116... ...
Universal prevention could include any activity that generally promotes responsible use of alcohol and discourages irresponsible use of alcohol, or it could be specific to fetal alcohol syndrome. As described later, it is not clear whether these general interventions have had, or could ever have, an impact on FAS, ARBD, or ARND.
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From page 117... ...
and health care providers. No universally safe level of alcohol consumption has been identified for pregnant women.
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From page 118... ...
Many groups, such as the March of Dimes, the American College of Obstetrics and Gynecology, and drug store chains, have put out pamphlets with information about FAS; the National Organization on Fetal Alcohol Syndrome recently sponsored public service announcements about FAS by popular musicians Bonnie Raitt and Queen Latifah. Health care providers can and should engage in universal prevention interventions.
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From page 119... ...
Therefore, as discussed in Chapter 5, proxy measures of the impact of prevention activities are appropriate to consider. Relevant proxy measures might include knowledge, attitudes, and beliefs, as well as prevalence of drinking by pregnant women.
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From page 120... ...
These interventions involve different levels of targeting and intensity compared to universal prevention interventions. Some selective prevention is stimulated by general public information (universal prevention)
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From page 121... ...
Special selective prevention interventions could be designed based on these factors. Role of the Father Because the Committee to Study Fetal Alcohol Syndrome views the targets of FAS prevention activities as appropriately including more than just women, the partners of women who drink could be included in selective prevention activities as well.
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From page 122... ...
When appropriate, men should be encouraged to enter treatment for alcohol abuse, both for their own health and well-being and to make it easier for the pregnant woman to stop drinking. However, since many women who are at high risk for FAS are unmarried, in very unstable relationships, or both, it is important to tailor interventions to these situations.
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From page 123... ...
Clinicians should be trained to question women in an appropriate manner about their drinking and contraceptive histories. If a woman drinks alcohol and has other risk factors for FAS, health care providers should deliver selective or indicated prevention interventions, and this requires training and preparation.
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From page 124... ...
Obstetrician gynecologists and other primary health practitioners who provide health care to women often serve as counselors for questions and concerns related to women's general health and reproduction, and have opportunities to advise women about the potential risks of alcohol use. Annual routine health visits and pre- and postnatal visits provide multiple opportunities to discuss alcohol and the effects of alcohol consumption on health.
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From page 126... ...
, a series of 25 questions, many drawn from earlier alcoholism surveys (Seizer, 19711. Alcohol screening tests such as the MAST and the CAGE, although not designed to screen pregnant women, have served as sources of items for other questionnaires that have been found useful in screening for at-risk drinking during pregnancy.
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From page 127... ...
For example, they could help establish dose-response relations for prenatal alcohol exposure and adverse fetal outcome and could help delineate effects of alcohol from other confounders. Studies will need to continue to explore the validity and efficiency of possible tests, examine the specific impact of pregnancy in addition to gender, as well as the impact of other confounding variables including nutrition, age, parity, smoking, other substance abuse, and preexisting illnesses and conditions.
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From page 128... ...
Although the mechanism by which serum GGT is heightened from chronic alcohol consumption has yet to be defined, GGT has become a widely used laboratory screening test for alcohol abuse and alcoholism because of its proven sensitivity (39-78%) and specificity (11-50%)
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From page 129... ...
Simultaneously, macrocytosis will occur and persist until all alcohol consumption has stopped. Alone, the sensitivity of MCV is 26-71% and the specificity is 20-74% and has been found to detect only 30-40% of subjects with an alcohol problem.
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From page 130... ...
HbAA levels have been studied in pregnant women who were followed until delivery (Niemala et al., 1991~. The offspring were assessed and of 19 alcohol abusing women, 8 had infants diagnosed as having "fetal alcohol effects." HbAA levels were elevated in 68 percent of women who had alcohol-affected babies but only in 28 percent of the mothers who abused alcohol while pregnant but gave birth to non-affected babies.
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From page 131... ...
Brief Interventions and Referral Assessing risk during pregnancy through screening is an essential step toward educating pregnant women about the potential dangers of such behaviors. Once a problem has been identified, the health provider must make an appropriate intervention or treatment referral.
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From page 132... ...
Brief interventions or referral to professionals trained in assessing and treating women who abuse alcohol may be the first steps toward recovery for some patients. Professional Education Although routine screening for alcohol use may be a desirable goal, much will have to change before it becomes a reality.
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From page 133... ...
The program is intended to improve the identification, care, and treatment of chemically dependent pregnant women and their children. It includes units on diagnosis of alcohol or other substance abuse, intervention and referral for such abuse, and relevant legal and ethical issues.
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From page 134... ...
All women were counseled about the negative effects of alcohol, tobacco, and other drug use on their infants and were advised to stop using these substances. Women troubled by the information or identified as having significant substance abuse problems were referred for supportive counseling.
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From page 135... ...
Although other frameworks for describing prevention activities draw a line between prevention activities and treatment, indicated prevention of FAS includes treatment for alcohol abuse in a pregnant woman or for a woman highly likely to become pregnant. Thus, discussions about alcohol treatment for pregnant women and treatment outcome research are included in this chapter on prevention.
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From page 136... ...
Therefore, any health care provider who comes in contact with women who abuse alcohol should consider brief intervention therapies and referral to more formal alcohol abuse treatment, if appropriate, and counsel her regarding the risks of prenatal alcohol exposure. Women of reproductive age who abuse alcohol should also be offered referral and access to birth control information and services.
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From page 137... ...
If further research indicates more definitively prenatal effects of alcohol exposure at levels less than that which causes FAS, ARBD, or ARND, then decreases in drinking of any sort would be a valuable goal of prevention intervention for birth defects. There have been some attempts at forced treatment and incarceration of pregnant woman who abuse illegal substances, particularly crack cocaine.
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From page 138... ...
Although several programs have been described and there have been a number of recent federal and state efforts to provide or expand treatment services for alcohol- and drug-abusing women, treatment programs may not be readily available to many of the women at risk. Treatment Outcome Research on Alcohol Abuse in Women The lack of data on effectiveness of treatment for pregnant women who
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From page 139... ...
There is at this time no strong evidence of gender differences in the determinants of treatment seeking, treatment retention, or outcome (IOM, 1990; McLellan et al., 19944; of modalities that may be better for women than for men; or of relative relapse in female versus male substance abusers. Research has not evaluated whether the multicomponent package approaches commonly recommended for substance-abusing women are more effective than unimodal approaches, although one controlled trial has suggested better outcomes for women in a single-gender program than in a mixedgender program (Dahlgren and Willander, 19891.
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From page 140... ...
, have been perceived as male oriented, evidence suggests that women may be more likely than men to attend self-help groups (Humphrey et al., 1991~. The high level of social support provided in self-help groups and the recent development of specialized women's groups may make this a good option for pregnant women who abuse alcohol.
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From page 141... ...
Addressing Barriers to Research The lack of controlled trials of treatments for pregnant women at risk for delivering FAS infants highlights the many challenges involved in conducting this type of research. However, these challenges can be met, and systematic controlled evaluation of treatments for pregnant substance-abusing women is not impossible (Carroll et al., 1995)
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From page 142... ...
Case management of women who have had one or more FAS children can help protect against further FAS children; help maintain better health status; coordinate substance abuse care throughout various institutions and agencies; and tailor care to specific social and medical needs of the woman, her family, and her children. Case management involves all members of the extended family and should include enlisting the positive action of the male partner.
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From page 143... ...
Setting up an FAS prevention initiative with programmatic goals and objectives will facilitate evaluation of programs with multiple outcome measures, e.g., maternal outcome such as reducing alcohol consumption and infant outcome such as birth weight or FAS symptoms. Many prevention activities are evaluated for process outcomes only.
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From page 144... ...
Nevertheless, NIAAA-funded research has elucidated fundamentals of alcohol abuse prevention and treatment in general, and some projects funded in the future could focus on or at least include women and pregnant women. Several of the CDC state-based prevention projects are involved in what the committee would consider universal prevention activities.
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From page 145... ...
SUMMARY The detailed prevention measures described above represent a progression through a spectrum. Universal prevention is used to promote general knowledge and social conditions that serve to reduce substance abuse and to promote healthy pregnancy practices.
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From page 146... ...
Indicated prevention interventions: · The committee recommends that a high priority be placed on research efforts to design, implement, and evaluate prevention interventions that can effectively guide pregnant women who drink heavily to alcohol treatment. Research or programs should also include: implementation of appropriate screening tools, including bio markers of alcohol exposure, to identify women who are drinking moderate to heavy amounts of alcohol during pregnancy; assessment of methods to involve women's partners and family members in interventions to decrease or stop drinking; incorporation of comprehensive reproductive counseling and con
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From page 147... ...
Programs developed or studied should include the following: specific demographic groups that have been demonstrated to be at higher risk for FAS, ARBD, and ARND, as well as those who exhibit risk factors associated with moderate to heavy alcohol consumption during pregnancy; and - implementation of prevention efforts in a wide range of communities and media; Universal prevention interventions: · The committee recommends that although data are insufficient regarding the effectiveness of universal prevention interventions, such interventions should be continued to raise awareness about the risks of FAS, ARBD, and ARND. However, the most important approach to universal prevention is probably the development of a medical environment in which concepts of the risk of FAS, ARBD, and ARND are incorporated into routine health care.
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From page 148... ...
Influence of socio-economic factors on the occurrence of Fetal Alcohol Syndrome. Advances in Alcohol and Substance Abuse 1987; 6: 105-118.
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From page 149... ...
Fetal Alcohol Syndrome: A challenge for the community health nurse. Journal of Community Health Nursing 1984; 1:99-110.
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From page 150... ...
Fetal Alcohol Prevention and Education Family Album, Developed by the Spokane Tribe of Indians Fetal Alcohol Program; Spokane Tribal Community Action Team, Wellpinit, Washington. Finkelstein N
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From page 151... ...
A pilot project on fetal alcohol syndrome among American Indians. Alcohol Health & Research World 1983; 7:3-9.
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From page 152... ...
Serdula M, Williamson DF, Kendrick JS, Anda RF, Byers T Trends in alcohol consumption by pregnant women: 1985 through 1988.
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From page 153... ...
Streissguth AP, Aase JM, Clarren SK, Randels SP, LaDue RA, Smith DF. Fetal alcohol syndrome in adolescents and adults.
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