Preventing Alcohol and Other Substance-Exposed Pregnancies: A National Perspective

1. Preventing Alcohol and Other Substance-Exposed Pregnancies: A National Perspective Mary Kate Weber, MPHCityMatCH Practice Collaborative MeetingOctober 17, 2011 Office of the Director National Center on Birth Defects and Developmental Disabilities

2. 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

3. What is the Problem?

4. 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

5. At-Risk Alcohol and Other Substance Use (continued) • 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

6. 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

7. 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

8. The Story of Iyal

9. Prevalence of Any Alcohol Use among Women Aged 18-44 Years – United States, 1991-2005 Behavioral Risk Factor Surveillance System, 1991-2005, United States

10. Prevalence of Binge Drinking among Women Aged 18-44 Years – United States, 1991-2005 Behavioral Risk Factor Surveillance System, 1991-2005, United States

11. 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

12. 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

14. 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.

15. 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 level Source: 2004-2008 SAMHSA National Surveys on Drug Use and Health

16. 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

17. Strategies to address alcohol-exposed pregnancy

18. 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

19. 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

20. 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 Strategies that have been used to reduce alcohol use and alcohol-exposed pregnancies

21. 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

22. 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

23. Point-of-Purchase Warning Posters • Typically posted in bars, liquor stores and restaurants • While posters alone have not been shownto 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)

24. Alcohol and Pregnancy: Mandatory Warning Signsas of January 1, 2011 NIAAA Alcohol Policy Information System, 2011 http://www.alcoholpolicy.niaaa.nih.gov

25. 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

26. 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

27. 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 Population-based Interventions to Reduce Excessive Alcohol Use

28. 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 What is the Community Guide?

29. Community Guide – Alcohol Reviews www.thecommunityguide.org/alcohol/index.html

30. 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)

31. 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

32. 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% Project CHOICESEfficacy Study Results

33. 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

34. Discussion • What kinds of strategies have you used in your city/state/community to address substance-exposed pregnancy? • What has worked? What hasn’t?

35. Examples of national prevention activities

36. 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 7,875health care professionals • New funding cycle (2011-2014) • In 2011, awarded 4 cooperative agreements • Emphasis on SBI implementation in addition to traditional core training competencies

37. FASD Regional Training Centers, 2011-2014 Washington Maine Montana Vermont Minnesota North Dakota Michigan New Hampshire Oregon Wisconsin Massachusetts South Dakota Idaho New York Wyoming Michigan Rhode Island Connecticut Pennsylvania Iowa Nebraska New Jersey Nevada Ohio DC Indiana Delaware Illinois Utah Maryland West Virginia Colorado California Virginia Kansas Missouri Kentucky North Carolina Tennessee Arizona Oklahoma Arkansas South Carolina New Mexico Mississippi Georgia Alabama Texas Florida Louisiana Alaska Arctic RTC, Univ of Alaska Anchorage Midwestern RTC, Saint Louis Univ Great Lakes RTC, Univ of Wisconsin Hawaii Southeastern RTC, Meharry Medical College Frontier RTC, Univ of Nevada Reno

38. 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

39. 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)

40. 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

41. 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. CHOICES Dissemination

42. 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

43. 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

44. 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

45. 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

46. Questions? Contact Information: Mary Kate Weber muw1@cdc.gov 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.