Preventing Alcohol and Other Substance-Exposed Pregnancies: A National Perspective
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Transcript of Preventing Alcohol and Other Substance-Exposed Pregnancies: A National Perspective
Mary Kate Weber, MPHCityMatCH Practice Collaborative Meeting
October 17, 2011
Preventing Alcohol and Other Substance-Exposed Pregnancies: A National Perspective
Office of the DirectorNational Center on Birth Defects and Developmental Disabilities
Today’s Presentation Public health burden of risky alcohol and
other substance use among women of reproductive age
Strategies to reduce alcohol-exposed pregnancy and unhealthy alcohol use
Examples of national prevention efforts
What is the Problem?
At-Risk Alcohol and Other Substance Use
Pose significant health risks to women of reproductive age, and for those who become pregnant, to their children
One of the strongest predictors of substance use during pregnancy is substance use before pregnancy
Early identification of substance use in the preconception period offers an opportunity to help women reduce major health risks, including risks to their children
Evidence-based methods for screening and intervening on harmful use of alcohol, tobacco and illicit drugs have been developed and are recommended for use in primary care settings for women of reproductive age
At-Risk Alcohol and Other Substance Use (continued)
Adverse Outcomes Associated with Substance Use During Pregnancy
Alcohol use Spontaneous abortion, prenatal and postnatal growth
restrictions, fetal alcohol spectrum disorders Maternal smoking
Intrauterine growth retardation, prematurity, low birth weight, sudden infant death syndrome, orofacial clefts
Illicit drug use Cocaine: increased risk for low birth weight,
prematurity, perinatal death, abruptio placenta, and small for gestational age births
Marijuana: linked to effects on intellectual development in young children
Women who use illicit drugs often have higher rates of STDs, HIV, hepatitis, domestic violence and depression
Alcohol Use during Pregnancy
Fetal Alcohol Spectrum Disorders (FASD) Describes a range of effects that can occur in an
individual whose mother consumed alcohol during pregnancy
Physical, mental, behavioral, and/or learning disabilities with lifelong implications
Not intended as a clinical diagnosis Fetal Alcohol Syndrome (FAS)
Characterized by specific facial features, growth deficits, and central nervous system abnormalities
Prevalence Rates FAS - range from 0.2 to 1.5 cases per 1,000 live births FASD - estimated to be at least three times as many
cases as FAS The lifetime cost of care for an individual
with FAS in 2002 was estimated to be $2 million
The Story of Iyal
Prevalence of Any Alcohol Use among Women Aged 18-44 Years – United
States, 1991-2005
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Behavioral Risk Factor Surveillance System, 1991-2005, United States
Prevalence of Binge Drinking among Women Aged 18-44 Years – United
States, 1991-2005
02468
10121416
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Behavioral Risk Factor Surveillance System, 1991-2005, United States
Risks of Binge Drinking to Women’s Health
Contributes to over 11,500 deaths among women in the U.S. each year—approximately 32 deaths per day
Increases the risk for breast cancer, heart disease, and stroke, all of which are leading causes of death in women
Risk factor for sexual assault, especially among young women in college settings
Increases the risk for unintended pregnancy
Risks of Binge Drinking to Women’s Health (continued)
Women who binge drink are more likely to have unprotected sex and multiple sex partners, which can increase their risk of acquiring HIV and other sexually transmitted diseases
Women who drink alcohol while pregnant increase their risk of having a baby with an FASD If a woman does not recognize that she is pregnant and
she continues drinking, she can expose her developing fetus to alcohol without realizing it.
Long term effects of binge drinking increases risk for certain types of cancer, alcohol-related liver disease, and heart problems
Percentage of Women Aged 15-44 YearsUsing Substances
Sources: SAMHSA, Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011. *Colliver, J. D., Kroutil, L. A., Dai, L., & Gfroerer, J. C. (2006). Misuse of prescription drugs: Data from the 2002, 2003, and 2004 National Surveys on Drug Use and Health (DHHS Publication No. SMA 06-4192, Analytic Series A-28). Rockville, MD: SAMHSAn, Office of Applied Studies.
Past Month Substance Use among American Indians or Alaska Native Women Aged 18 or Older Compared with the National Average,
2004-2008
*Differences are significant at .05 levelSource: 2004-2008 SAMHSA National Surveys on Drug Use and Health
Discussion Do these findings reflect what is going on in
your city/state/community? How are they similar or different?
Tool 1: Mapping the Problem & Context
Strategies to address alcohol-exposed
pregnancy
Preventing Alcohol-Exposed Pregnancies (AEP)
Alcohol use during pregnancy continues to be a serious public health problem
Women who are sexually active and drinking alcohol are at risk of having an AEP since they may be drinking and not know they are pregnant for several weeks or more
Almost half of pregnancies in U.S. are unplanned
FASDs are 100% preventable
Reducing Alcohol-Exposed Pregnancies: A Report of the National Task Force on
Fetal Alcohol Syndrome and Fetal Alcohol Effect, 2009
Goal: to review evidence-based prevention strategies to reduce AEPs and provide recommendations for prevention of AEPs
Utilized Institute of Medicine Prevention Framework strategies: Universal Selective Indicated
Strategies that have been used to reduce alcohol use and alcohol-exposed
pregnancies Surgeon General’s advisories Alcoholic beverage warning labels Point of purchase signage Health communication campaigns Population-based strategies to reduce
alcohol use Alcohol screening and brief intervention
(SBI) Project CHOICES Case management with highest risk
women
Surgeon General Advisories on Alcohol Use in Pregnancy
1981 Surgeon General’s Advisory on Alcohol and Pregnancy
2005 Surgeon General’s Advisory on Alcohol Use in Pregnancy
Alcoholic Beverage Warning Labels
Alcoholic Beverage Warning Label Act 1988
Studies on the impact of the warning label on alcohol use: A significant number of people
reported seeing the warning labels; some effects on alcohol use on light drinkers but not heavy drinkers
Overall, exposure to the label does not reduce alcohol use but has increased awareness in some groups
Point-of-Purchase Warning Posters
Typically posted in bars, liquor stores and restaurants
While posters alone have not been shown to change alcohol-related behaviors, they Can raise awareness of health
and safety risks associated with drinking and pregnancy
Reinforce the beverage warning label
Use this strategy in combination with others
Resource: Mandatory Point-of-Purchase Messaging on Alcohol and Pregnancy (2008)
NIAAA Alcohol Policy Information System, 2011http://www.alcoholpolicy.niaaa.nih.gov
Alcohol and Pregnancy: Mandatory Warning Signsas of January 1, 2011
Communication Campaigns
Increase knowledge and awareness about a health issue
Can complement or promote FASD prevention efforts
Rarely result in behavior change Can be costly; however, new
mediaoffers opportunities for creativity
Careful planning is needed Evaluation is critical but is often
not done
Are these strategies effective at reducing AEPs?
There is insufficient evidence to indicate that these strategies are effective in reducing AEPs; however, they Are important strategies for increasing
public awareness and political will Help raise the visibility of fetal alcohol
spectrum disorders as a public health concern
Complement a comprehensive approach to FASD prevention
More research is needed to explore the effects of these kinds of strategies
Population-based Interventions to Reduce Excessive Alcohol Use
Population-based interventions WHO report No Ordinary Commodity Community Guide reviews
Effective population-based alcohol interventions could ultimately impact alcohol consumption rates among women of reproductive age
What is the Community Guide? Resource of evidence-based
recommendations for public health policy and practice
Assessed effectiveness of over 210 public health interventions in 18 topic areas and settings, including excessive alcohol use
CDC provides scientific and administrative support to the Task Force on Community Preventive Services
Community Guide – Alcohol ReviewsInterventions Directed Toward the General Population
Regulation of alcohol outlet density
Recommended based on sufficient evidence
Maintaining limits on days of sale Recommended based on strong evidence
Maintaining limits on hours of sale
Recommended
Increasing alcohol taxes Recommended based on strong evidence
Enhanced enforcement of overservice laws
Recommended
Dram shop liability RecommendedPrivatization of retail sales Insufficient EvidenceResponsible beverage service training
Insufficient EvidenceInterventions Directed Toward Underage Drinkers
Enhanced enforcement of laws prohibiting sales to minors
Recommended based on sufficient evidence
www.thecommunityguide.org/alcohol/index.html
Has been shown to reduce risky alcohol consumption in a variety of settings and among various population groups
Recommended by the U.S. Preventive Services Task Force for people 18 and older, including pregnant women
National Task Force on FAS identified brief alcohol interventions as the most promising approach to reduce alcohol use among women of reproductive age
Alcohol Screening and Brief Intervention (SBI)
Project CHOICES Intervention
Four counseling sessions based on standard brief intervention components
Dual focus: reducing alcohol use, improving contraceptive use
Use of motivational interviewing approach One family planning consultation & services
visit
Project CHOICESEfficacy Study Results
Those in intervention group 2x more likely to be NOT at risk for AEP at 3, 6, 9 months than those in control group
71% in study at 9-month follow-up Both groups had reduced AEP More intervention women changed both
behaviors Effective approach to reducing AEP
Not at risk by: Intervention Control
• Reducing alcohol use 49%40%
• Improved contraception 56% 39%
Parent-Child Assistance Program (PCAP)
Intensive case-management intervention serving high-risk alcohol and/or drug abusing mothers and their families To prevent future substance-exposed births To intervene with women with FASDs and children who
might be affected Assist women in obtaining treatment,
staying in recovery, and addressing other life challenges
Results of original studies were positive for participation, abstinence, use of reliable birth control and decreases in subsequent pregnancies
Discussion What kinds of strategies have you used in
your city/state/community to address substance-exposed pregnancy? What has worked? What hasn’t?
Examples of national prevention activities
FASD Regional Training Centers (RTCs) Purpose: to educate medical and allied health students
and practitioners in the prevention, identification, and treatment of FASDs
Previous Cycle of RTCs (2008-11) In 2008, awarded 5 cooperative agreements Conducted 542 trainings/events Reached 5,535 students/residents and 7,875
health care professionals New funding cycle (2011-2014)
In 2011, awarded 4 cooperative agreements Emphasis on SBI implementation in addition to traditional
core training competencies
Washington
Montana
Oregon
Nevada
California
Utah
ArizonaNew Mexico
Colorado
Idaho
Wyoming
North Dakota
South Dakota
Minnesota
IowaNebraska
Kansas
TexasFlorida
Mississippi
Louisiana
Alabama
Georgia
South Carolina
North Carolina
Virginia
Maine
New York
Michigan
Wisconsin
Oklahoma
Missouri
ArkansasTennessee
Kentucky
IllinoisIndiana
Michigan
Ohio
West Virginia
DC
MarylandDelaware
New Jersey
Vermont
Rhode IslandConnecticut
New Hampshire
Massachusetts
Alaska
Hawaii
Pennsylvania
FASD Regional Training Centers, 2011-2014
Arctic RTC, Univ of Alaska AnchorageMidwestern RTC, Saint Louis UnivGreat Lakes RTC, Univ of WisconsinSoutheastern RTC, Meharry Medical CollegeFrontier RTC, Univ of Nevada Reno
American College of Obstetricians and Gynecologists
(ACOG) In 2005, CDC partnered with ACOG to
develop a tool kit for women’s health providers Focused on screening, educating, and intervening with
women at risk for an alcohol-exposed pregnancy Over 17,000 copies distributed to ACOG membership
and others Recent ACOG survey found most ob/gyns were unaware
of the toolkit In 2010, CDC awarded a contract to ACOG
to: Re-assess the FASD Prevention Tool Kit Integrate FASD prevention information and materials
into ACOG activities and disseminate to ACOG membership
Establish a relationship with CDC’s FASD RTCs to integrate primary prevention materials and the tool kit into RTC trainings
CHOICES Plus: A Preconception Approach to Reducing Alcohol and
Tobacco-exposed Pregnancies
Clinical trial aimed at testing the efficacy of combining a facilitated referral for smoking cessation with the CHOICES intervention to reduce risks for alcohol and tobacco-exposed pregnancies
Awarded to University of Texas at Austin (2008-2012)
Translation of the CHOICES Intervention Two sites funded in 2009 to implement
CHOICES in STD clinics Colorado Dept of Public Health and Environment/Denver
Metro Health Clinic Baltimore City Health Department/Johns Hopkins
University Two sites funded in 2010 to implement
CHOICES in CHCs and Family Planning Clinics Alta Med Corporation, Los Angeles CA New York City Health and Hospitals
Inter-Agency Agreement in 2010 with Indian Health Service Oglala Sioux Tribe in South Dakota
CHOICES Dissemination
Developed intervention and training materials, based on the original CHOICES protocol & related resources, for public health providers serving women of childbearing age: Counselor Manual Client Workbook Assessment Tools Training Curriculum Resources-training videos, on-line tutorials, etc.
Enhanced Resources for FASD Prevention and Intervention through National Networking, Education, &
Dissemination In 2010, CDC’s FAS Prevention Team
awarded a four-year cooperative agreement to NOFAS to: Enhance/expand the NOFAS National & State Resource
Directory Engage/enhance existing network affiliate members and
increase the number of affiliate organizations and build capacity among network members
Enhance/expand the NOFAS Information Clearinghouse and disseminate resources/materials
Conduct media outreach
CityMatCH Practice Collaborative Project
Project Purpose Pilot a multi-city urban practice collaborative focused on
addressing alcohol and other substance misuse among women of reproductive age
• Increase awareness and education about the risks of substance use during pregnancy & their associated adverse effects, and
• Enhance capacity of providers to deliver screening, brief intervention, and referral services for women of reproductive age
Practice Collaborative Teams 6 local teams selected through an application process Develop and implement local action plans to address
this issue
SAMHSA’s FASD Center for Excellence Provides training and technical assistance Maintain FASD Information Resource Center
& FASD Center Website Developing FASD Treatment Improvement
Protocol (TIP) Fund 23 local, state and juvenile court to
implement evidence-based interventions National Association of FASD State
Coordinators
www.fasdcenter.samhsa.gov
National Institute on Alcohol Abuse and Alcoholism
Conducts both basic science and prevention research on a wide range of topics related to alcohol
Manages a large FASD research portfolio Coordinates the Interagency Coordinating
Committee on FASD SBI-related materials include:
Helping Patients Who Drink Too Much: A Clinician’s Guide Rethinking your Drinking – rethinkingdrinking.niaaa.com New “Alcohol and Brief Intervention for Youth”
practitioner guide
www.niaaa.nih.gov
For more information on “10 Years of Service”http://www.cdc.gov/ncbddd/tenyears/
Questions?
Contact Information:Mary Kate [email protected]
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.