Best Practices : Fetal Alcohol Syndrome/Fetal Alcohol Effects and the Effects of Other Substance Use During Pregnancy
3. Primary Prevention
Primary prevention activities are undertaken with a healthy population to maintain or enhance physical and emotional health. Primary prevention activities typically focus on behaviour change, systems, or the environment.
At the broadest level, primary prevention takes a population health approach that seeks, through public policy, to address the socioeconomic factors that have been shown to affect the health of a population; for example, education, employment, income levels and social support. Although the picture is far from complete, epidemiological data presented for Canada and the US suggest the prevalence of FAS and FAE is greater in lower socio-economic families and communities. Indeed, the socioeconomic status and circumstances of the biological mother have been described as “permissive factors” in the prevalence of FAS (Abel and Hannigan, 1995).
The Canadian Federal, Provincial and Territorial Advisory Committee on Population Health (1994) has endorsed a framework intended to address these broad determinants of health. This framework has led to activities to address the overall health of “at-risk” pregnant women, through programs such as the Canada Prenatal Nutrition Program (CPNP). These programs have the potential to address substance use issues, mental health and violence issues, as they co-occur (Clarren, 1999; Ernst, et al., 1999; Horrigan et al., 2000).
Various regulatory approaches have been recommended, and in some jurisdictions implemented, to reduce alcohol consumption (for example, increased taxation, advertising regulations, responsible service, and limiting hours of service or number of outlets).
The regulatory measure to reduce consumption that is most supported by evidence is increased pricing through taxation. A number of studies have shown alcohol consumption, even among heavy drinkers, to be quite responsive to price, with one study showing women reducing their consumption due to price increases more than men (Abel, 1998a).
A number of Ontario communities have adopted municipal alcohol policies that reflect a health and safety orientation. An evaluation of a community alcohol policy initiative using comparison communities failed to demonstrate an impact on general population consumption (Giesbrecht and Douglas, 1990); however, those municipalities that fully implemented a municipal alcohol policy reported a decline in alcohol related problems (Douglas et al., 1997).
An alcohol policy initiative on a native reserve in Ontario led to greater regulation of the sale and service of alcohol at events. Early findings indicate a reduction of some problems; however, drinking during pregnancy is not discussed (Lauzon et al., 1998).
In an aggressive attempt to limit consumption, some isolated northern communities have opted to prohibit the sale of alcohol in the community. Early evidence from one study in Alaska suggests that a community alcohol ban resulted in a significant reduction in heavy alcohol use among pregnant women in the short-term (Bowerman, 1997). Aside from this preliminary report, the potential effects of such regulatory approaches on the prevalence of heavy alcohol use during pregnancy have not been studied (May, 1995). However, if prohibitionist policies do not have broad community support, they can result in unintended negative social or community effects, such as increased criminality. These effects need to be considered in evaluating effectiveness (Skirrow and Sawka, 1986).
Another primary prevention strategy is mandated alcohol container warning labels. In the US, legislation requiring the labeling of all alcohol bottles came into effect in November, 1989. Hankin (1994) found an initial increase in FAS awareness, and a decrease in alcohol consumption during pregnancy, following the implementation of this legislation. Unfortunately, this reduction only occurred in women whose drinking patterns placed them at low risk. Women who drink heavily during pregnancy do not appear to be affected by warning labels. Furthermore, the initiative was criticized as the labels lack uniformity, and are harder to see than US cigarette package warnings (Blume, 1996).
Graves (1993) compared the awareness of the adverse consequences of drinking during pregnancy in the US where there is mandatory labeling, to Ontario residents, where there is no mandatory labeling. Small increases in awareness in the US sample were found. Men aged 18 to 29 who were heavy drinkers were most likely to be aware of the warning labels.
In one of several related studies, Greenfield et al. (1999) found that higher proportions of the young, male heavy-drinking population were more aware of the labels. Greenfield et al. (1999) also found a positive relationship between the amount of exposure to the label and conversations about drinking and pregnancy; awareness of the labels was not limited to the most health conscious.
Fenaughty and MacKinnon (1993) studied the effectiveness of a legislated warning poster in the state of Arizona. The poster was required in all establishments selling alcohol, and included the statement, “Warning: Drinking Distilled Spirits, Beer, Coolers, Wine And Other Alcoholic Beverages During Pregnancy Can Cause Birth Defects”. They sampled college students’ knowledge of the effects of drinking during pregnancy prior to and after the implementation of the poster law. Students were primarily young (mean age 20 years) and white (81.4%). The proportion of subjects who had consumed at least one alcoholic drink in the past month was 77%. Following the implementation of the poster law, students were more aware of the poster and its message, but it had minimal impact on their beliefs regarding the effect of alcohol on the fetus. Women and older subjects were more likely to be aware of the poster than men or younger subjects. Data regarding any potential changes to the students’ drinking behaviour were not collected.
In Canada, despite interest from various groups, the only jurisdiction requiring alcohol beverage warning labels is the Yukon. The labels were implemented as the result of a policy decision rather than legislation. Some municipalities in British Columbia have by-laws mandating posted information on the effects of alcohol use during pregnancy. The impact of these regulations has not been evaluated.
This review located descriptions of several non-mandated awareness-raising initiatives from a number of jurisdictions in Western Canada (Casiro et al., 1994; Asante and Robinson, 1990; Ridd, 1999; Saskatchewan Institute on Prevention of Handicaps, 1999; Kellner, 1998). These programs have included media campaigns, billboards, warnings on till slips in liquor stores and on alcohol beverage packaging, primarily bags. Unfortunately, the goals of such programs are generally not clearly articulated, making it difficult to judge their effectiveness. For example, it is not clear whether the goals of such programs are to change the behaviour of high-risk women, to prevent any drinking or other substance use during pregnancy, or simply to create public awareness of the issue.
In Manitoba, a television campaign using public service announcements that ran during prime and non-prime time hours for 10 weeks was evaluated (Casiro et al., 1994). Investigators surveyed the same general population sample before and after the mass media campaign on a number of prenatal health questions, and found that the alcohol-related questions were the only ones where awareness had changed.
Given the tremendous array of messages generated by today’s media, one of the factors limiting the effectiveness of public awareness campaigns could be that a particular message is simply not seen enough. Kaskutas and Graves (1994) reported on a US national study of those exposed to pregnancy and alcohol messages, and found a positive relationship between the number of exposures to multiple message sources and reduced drinking in the overall population, including women under 40 years of age. However, the design of the study could not establish causality, and the authors acknowledge that behaviour change can bring about heightened awareness of messages.
Statements and guidelines published by credible sources can be important tools for creating awareness of an issue. In 1993, the Canadian Centre on Substance Abuse (CCSA) and the (then) Addiction Research Foundation (ARF) of Ontario jointly published low-risk drinking guidelines (Anderson et al., 1993). These guidelines included the advice to pregnant women that they would be advised to abstain from alcohol, and, given the relatively higher risk involved in the first trimester, that women who are planning a pregnancy avoid drinking. Another key Canadian publication, the Joint Statement: Prevention of Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (FAE) in Canada, led by the Canadian Pediatric Society and signed by 19 organizations (Health Canada, 1996), was an important effort to provide consensus-based guidance to health care professionals. While both of these publications were widely circulated, neither was evaluated for its impact.
Some FAS awareness raising messages have been criticized as “alarmist”, leading to unnecessary anxiety, and possible termination of pregnancy in low-risk women, while failing to reach the women at greater risk (Reynolds et al., 1994; Koren, 1996; Abel, 1996).
Unless research can establish a safe threshold of consumption of alcohol for pregnant women, public awareness campaigns must navigate a fine line. They must avoid creating undue anxiety in women who may have inadvertently exposed their fetus to small amounts of alcohol or other substances on the one hand, while creating awareness of the risks associated with particular patterns (for example, frequent and binge drinking), and particular sub-populations (such as multiparous women who drink during pregnancy), on the other hand. Reynolds et al. (1994), as a result of assessing the need for drug-related health promotion materials for pregnant women in Canada, recommended that materials and messages be developed with very specific groups in mind, avoid fear-arousing messages, and reflect the hierarchy of risk that exists.
In spite of their limited effectiveness, Fenaughty and MacKinnon (1993) suggest that public awareness campaigns may be effective in the long-run in preventing women from developing drinking patterns that would place them at-risk when pregnant. May (1995) also speculates that public awareness efforts may “spark” behaviour change in a way similar to that attributed to public information on smoking and heart disease. Others suggest that women who are attempting to avoid alcohol and other substance use during pregnancy need support from their partners, family and communities, and that public awareness campaigns can help engender this support (Finkelstein, 1993, 1994; Little et al.,1990). Finally, it has been suggested that an informed public may be more inclined to support public expenditures to address this issue (Streissguth, 1997).
Multi-component programs typically aim to increase awareness of FAS among both men and women through a variety of means. Perhaps the most promising use of awareness-raising campaigns is as one part of multi-component community-wide programs. The Tuba City program involving Native populations in the US used a comprehensive approach to prevention and intervention that included awareness raising, training and a diagnostic component (LeMaster and Connell, 1994). Although the various elements of the initiative were not separately evaluated, the overall program was effective in promoting referrals and abstinence among pregnant women.
A well-designed multi-component campaign by the Alberta Alcohol and Drug Abuse Commission (AADAC), on behalf of the Alberta Partnership on FAS, was conducted during 1999-2000. Among other aims, the campaign intended to increase the awareness and profile of FAS. It employed television, radio and newspaper advertisements, and local initiatives that included private sector involvement. Eight hundred Albertans were surveyed prior to the campaign, with another sample surveyed immediately following the three month television campaign. A generally high level of awareness and support for action remained unchanged as a result of the campaign, according to a number of measures. However, public recall of information related to alcohol and pregnancy rose with 61% of Albertans reporting having seen, heard or read something about the issue before the mass media element of the campaign, compared to 73% after.
Other studies indicate that multi-component community prevention strategies can affect awareness and, possibly, levels of alcohol consumption by pregnant women (Streissguth et al., 1983; Smith et al., 1986). Elements include fully available birth control, substance-specific information provided to men and women, prenatal and outreach services, and professional training to identify, intervene, and support those at-risk.
Many employers, particularly medium and larger organizations, have workplace health promotion programs that, while focussing on larger aims, may contribute to primary prevention of FAS. Most company programs do not deal with substance use per se, but with a range of lifestyle behaviours that affect health. Health behaviours are, however, inter-related, and therefore may indirectly affect substance use.
Integral to the prevention of FAS and the effects of other substances is pregnancy planning. Women need to be aware that being sexually active, a frequent or heavy alcohol user, and not using contraception places them at-risk of an alcohol-exposed pregnancy (Floyd et al., 1999). Awareness about FAS issues is generally not sufficient for women in difficult relationships. Negotiating safe relationships, safe sex, and pregnancy planning, in these cases, is not straightforward.
A key target group for primary prevention is adolescents, because of the prevalence of binge drinking and sexual activity among teens. A recent large US study found that age at onset of alcohol use is a powerful predictor of later alcohol problems. The study found that 40% of those who began drinking alcohol at 14 years of age or younger experienced alcohol dependence at some point in their lives, compared to 10% who began drinking at age 20 or older (Grant and Dawson, 1997). By delaying age at onset, substance use/FAS/FAE prevention initiatives have the potential to minimize later problems.
Life Skills Training (Botvin, et al., 1995), a three-year school-based program designed to teach personal and social skills in combination with specific skills to resist social influence to use substances, has been found effective. A comprehensive school program that targeted an entire community using media efforts, a parent program, a community organization and health policy change (Pentz et al., 1989; Perry et al., 1996) also showed some positive effects.
Multi-component programs, involving media, community leaders, parents and the business and religious communities, show some effectiveness in preventing teenage pregnancy. The School-Community Model demonstrated a reduction of pregnancy and increased use of contraceptives over a six year period and may be an example of how to address the issue of FAS/FAE in schools (Paine-Andrews et al., 1996).
FAS-specific content should be accommodated in health education and family living courses. Topics at the high school level should include pregnancy planning, the teratogenic effects of alcohol, early symptoms of pregnancy, the importance of routine physical exams for sexually active female adolescents, the problems of confronting parents, and understanding the needs of those affected by prenatal alcohol exposure (Murphy-Brennan and Oei, 1999).
One such US school program developed for Aboriginal 6th and 8th grade students used a video in conjunction with 19 lessons and a project World Wide Web site. The study used a small randomized sample. It found a significant increase in knowledge after just two weeks (Mai et al., 1998).
Measures to control the sale and service of alcohol have shown some effectiveness in reducing heavy alcohol use during pregnancy, at least in the short-term. These measures are more likely to be effective when they have broad community support. The regulatory approach to raising awareness and changing behaviours related to FAS issues through warning labels and posters has only shown some effectiveness among lower risk women. More localized efforts to raise awareness through the use of media have shown little effect used in isolation. Greater impact is seen when they are part of a multi-component initiative. Well-conceived multi-component programs can be effective if they engage members of the community. Several school-based substance use problem prevention programs have demonstrated some effectiveness.
There is some evidence that measures to limit the availability of alcohol, such as bans on sales and importation that are broadly supported by the community, or price increases, can reduce heavy alcohol use by pregnant women at least in the short-term.
There is some evidence to support warning labels and posters as a means of increasing awareness and effecting short-term behaviour change among low-risk women. However, women who drink heavily during pregnancy do not appear to be affected by warning labels.
There is some evidence to support multi-component community-wide initiatives as a means of increasing awareness generally, reducing consumption for pregnant women, and promoting referrals.
There is moderate evidence to support the use of life-skills-based and multi-component school-community substance use prevention programs as a means of preventing or delaying substance use among youth and, in turn, reducing substance use problems among adults.
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