A month ago, the Centers for Disease Control in the US released its controversial guidelines recommending all women who “might be” pregnant abstain from alcohol and that all women who are pregnant stop drinking completely. While parts of the guidelines are appropriate, including that all pregnant women be talked to about alcohol use, the messaging is off. “Why take the risk?” the guideline asks. It suggests that women who drink during pregnancy are making a calculated, incorrect choice. The reality is far from it.
In my work as a neonatologist, I’ve looked after many, many babies. I’ve seen families of all ages, cultures and circumstances. I’ve never seen a mother who wanted to harm her growing baby. Yet, too often, I still see mothers who use alcohol during pregnancy, despite extensive educational campaigns about its harmful effects on the growing fetus.
Alcohol use in pregnancy can result in fetal alcohol spectrum disorder. FASD is a lifelong disability that may include intellectual and learning disorders, facial differences and social and emotional difficulties. Not all babies exposed to alcohol in utero develop FASD, but many do.
It’s easy to judge, but the truth is, consistently practising healthy behaviours is not as simple as it sounds. There are often many barriers that may affect a person’s ability to do what they know they should.
Studies show women who use alcohol in pregnancy often deal with many other problems at the same time, such as physical and mental health disorders, an abusive partner, addictions, homelessness and food insecurity. Designing programs to adequately support women in such situations can be challenging.
This is where InSight comes in. InSight is a Manitoba-based program where mentors work with women at risk of having an infant with FASD. Participants work with a mentor for three years to set and achieve goals for small, positive behavioural changes. The good news: it works.
In a recent report from the Manitoba Centre for Health Policy, my colleagues and I demonstrate women involved in the InSight program made many important gains. They accessed prenatal and other health care at greater rates, they reduced their use of alcohol both in and outside of pregnancy, and they had greater connections to social supports such as housing, income assistance and postnatal family support programs.
Their children were also more likely to be assessed for FASD, which likely results in connection to appropriate services, and ultimately, improves outcomes for the child. Importantly, we also found because of the women’s behavioural changes with mentor support, the children born to women during the program were less likely to be taken into the care of Child and Family Services.
But it wasn’t all good news. Our report indicates some of the benefits seen during the program did not continue after the women left the program. Some women previously engaged in InSight reported increased social isolation, most likely because they lost previous networks of support after changing their behaviours. Going forward, we must find a way to ensure before an InSight mentor is removed, appropriate other social supports are in place. Lasting change shouldn’t be expected to happen overnight.
Also, despite having fewer children taken into foster care overall, more newborns were taken into care during the InSight program than in our (lower-risk) control group. This can be prevented. The risk of having their babies taken away is a fear that can stop women from accessing supports to reduce their alcohol use during pregnancy. Separating mothers and their newborns increases the risk for postpartum depression and decreases breastfeeding, among other detrimental effects. The solution? It’s a systems problem. We have an opportunity here for child-protection agencies to work directly with the InSight program to reduce the occurrence.
InSight participants are already attending prenatal care and receiving other supports. Child-protective services should allow time for participants to benefit from the program before assessing the home situation. InSight could help provide whatever is needed to allow participants to take their newborns home wherever possible with appropriate surveillance to ensure the safety of the family. When faced with complex problems requiring complex solutions, many people don’t know where to start. Our evaluation suggests the women in InSight know where to start but need support to get there and stay there.
Addressing poverty, intimate-partner violence and mental health issues might take a while, but until we make progress on these pressing issues, expecting there to be quick fixes for reducing alcohol use in pregnancy is unrealistic.
Programs such as InSight are critical because they are non-punitive in addressing substance use and addictions and address the underlying determinants of disease. When we encounter families and patients affected by drug and alcohol use, we should ask why they got there and how we can help, instead of judging them.Steps to provide food security, housing and safety from violence go a long way toward solving the problem for mother and baby. As we have learned, preventing FASD is not just about telling women they have made the wrong choice if they drink during pregnancy, it’s about empowering women to make changes amid complicated and difficult circumstances.
This opinion piece is an updated version of an article that first appeared on the Evidence Network. It has been reprinted with their kind permission.