Family physicians learn to address alcohol use during pregnancy: CrossCurrents Autumn 2003

CrossCurrents

Angela Pirisi

Most physicians willingly embark on a discussion of prenatal care with clients, asking about folic acid intake and weight gain. Yet many may feel uncomfortable broaching the issue of alcohol use in pregnant women or women of childbearing age.

Gaps in physicians' knowledge and the stigma attached to alcohol discourages some physicians from addressing the issue in prenatal care, says Wendy Burgoyne, a health promotion consultant with Best Start: Ontario's Maternal, Newborn and Early Child Development Resource Centre, based in Toronto. Physicians may be uninformed about alcohol use in pregnancy, unsure of how to ask or advise clients about it or unaware of effective screening tools and services.

"When doctors do ask about alcohol use, it's often in a close-ended manner, such as 'You don't drink, do you?'," explains Dr. Peter Selby, an addiction specialist at the Centre for Addiction and Mental Health (CAMH) in Toronto. It's a sensitive topic, so physicians need to take a balanced, non-judgemental approach to encourage discussion of alcohol use. "By attributing a negative outcome to any drinking while pregnant, doctors may make it into a closet problem because of a woman's fear of being judged," cautions Selby.

Available screening tools such as TWEAK and T-ACE help by delicately framing questions in a way that is non-threatening, non-judgemental and open-ended to encourage more detailed, accurate information. Yet not many physicians know about or use them. A 2002 study published in the journal BMC Family Practice found that 75 per cent of 75 Toronto family physicians reported counselling pregnant women, and 61 per cent reported counselling women of childbearing age about alcohol use; yet none were aware of the current screening methods to accurately gauge alcohol use in these women.

Dr. Claudette Chase, president of the Ontario College of Family Physicians, and co-medical director of northern practice in Sioux Lookout, Ontario, believes that it's not effective to paint every woman with the same brush, and that strategies need to address the needs and attitudes of specific populations. She prefers to ask her own questions in a sensitive, non-judgemental way rather than use the screening tools available. "I would like to see funding aimed at smaller areas and specific populations and tools developed based on that research," says Chase. "I'm always looking for effective interventions that can be used cross-culturally."

"Many doctors aren't sure how to intervene or where to send patients, so they think, 'Why open up a Pandora's box if I don't know what to do with it?'," says Selby. Nonetheless, he believes that physicians who care for women before and during pregnancy have an important role in assessing alcohol use and providing timely advice, counselling and referrals. But the role has to be better defined and physicians need to feel supported in that role.

Encouraging physicians to integrate alcohol screening into client care requires three strategies, suggests Selby: Increase the importance of asking about alcohol use for all childbearing women, increase physicians' confidence in intervening and make it feasible for physicians to intervene. For example, taking a smoking and alcohol history could be incorporated as a standard practice in antenatal screening. This procedure requires training so that it is incorporated into practice and is not merely another box to be checked on the screening form.

Clients can also help guide the process. Nancy Poole, a research consultant on women and substance use at B.C. Women's Hospital and the B.C. Centre of Excellence for Women's Health, both in Vancouver, British Columbia, says that, according to the findings from her study on barriers to treatment for substance-using mothers, leading deterrents to getting treatment include shame, fear of losing their children, depression or low self-esteem and a lack of information about available help. Poole says that physicians also need to adjust their strategy to address the client's stage of readiness to accept help. Poole adds that physicians should also consider other issues that may accompany alcohol use, such as violence and mental health. Recent data from a Health Canada national survey of physicians' knowledge and attitudes towards fetal alcohol spectrum disorder (FASD) and diagnosis, which also dealt with prevention issues, found that only 13.5 per cent of physicians asked about a history of sexual or emotional abuse.

Statistics show that a growing proportion of Canadian women consume alcohol - 80 per cent now versus 67 per cent in 1986. US data from the Centers for Disease Control reveals that over 20 per cent of pregnant women drink alcohol. "Considering that about 50 per cent of pregnancies are unplanned, it's common for women to have consumed some alcohol while pregnant before knowing that they were," says Selby. "So you have to ask everyone, and not just after they become pregnant," he adds. Social stereotyping and assumptions run high, meaning that women of a higher socio-economic status tend not to get screened, while aboriginal women get stigmatized, and pregnant women in general are just assumed to know better than to drink, notes Selby.

Meanwhile, knowledge is lacking about the consequences of drinking during pregnancy. "Many family physicians are still saying it is okay to have one or two glasses of alcohol a day, but there is no such thing as moderate drinking during pregnancy," says Burgoyne. According to the Health Canada survey, among health care providers advising moderate drinking, less than 50 per cent defined in amounts what that meant. Lack of time is another factor reported by nearly two-thirds of surveyed physicians for not addressing alcohol use. But Selby points out that screening really doesn't take much time, since the process only involves a handful of questions.

That's why there has been a concerted effort to offer physicians the training they need to effectively address alcohol use. For example, Best Start's unique new program, "Supporting Change," aims to teach physicians three key clinical practices: ASK women about alcohol use using an effective screening tool, ADVISE women about the effects of alcohol on their baby and ASSIST women in getting counselling if required.

Other programs have focused on training physicians to identify FASD, but Best Start looks at alcohol screening specifically, which is essentially the first step in FASD diagnosis and prevention. The program has generated interest in various provinces, such as Quebec, which has translated Best Start's manual and plans to train physicians locally. British Columbia, Alberta and the Yukon have also requested information about the program. All training resources are available free of charge in electronic formats from Best Start, and the materials can be adapted to provincial needs. While the program was designed for family physicians, since they are usually the first link in the chain of prenatal care, the training is being modified for a wider range of health care providers.

Other efforts are also underway to help physicians address alcohol use in pregnancy. For example, British Columbia's Ministry of Children and Family Development is sponsoring a three-day program this autumn, which will train northern physicians to screen for alcohol use and FASD. Meanwhile, the Alberta Medical Association has posted clinical practice guidelines from the Alberta Partnership on Fetal Alcohol Syndrome on its Web site. Another program, launched in January 2003, is the B.C. Women's Hospital Fir Square Combined Care Unit, which provides five antepartum and six postpartum beds for women looking to stabilize or withdraw from drug use during pregnancy. St. Joseph's Health Centre in Toronto, where Selby is a consultant and one of the developers of a woman-centred program for substance-using pregnant women, collaborates with various agencies to deliver both addiction and obstetric services to these women.

Besides being able to address alcohol use in prenatal care, physicians also need a network in place so they can liaise and consult with other physicians and refer clients. Chase agrees: "When we do intervention, we need to have support." So far, what's available to them is an alcohol helpline run by Motherisk, a Toronto-based program that provides women with information and counselling around various pregnancy issues. The helpline allows physicians to enquire about available services for a certain client, and clients who have been or are consuming alcohol while pregnant can ask about concerns and risks.

Physicians also need to be made aware of and let their clients know about different treatment options, such as outpatient counselling, withdrawal management and residential treatment. For some women, safe withdrawal management and/or outpatient counselling may be better than residential treatment, says Poole. Another hurdle is that detox centres do not feel comfortable treating pregnant women, and until recently, many turned pregnant women away. Luckily, that has started to change, and treatment programs geared to women and pregnant women are cropping up. For example, the Alberta Alcohol and Drug Abuse Commission, a provincially funded agency, recently introduced enhanced services for women to address "women with alcohol or other drug problems who are pregnant or who may become pregnant."

Building a solid network calls for broad, systemic change, says Selby. Other care providers, such as nurses, midwives, case workers and substance abuse counsellors, need to be drawn into the circle. "Counsellors, for example, need to explore the risk of FASD, and look at birth control as a means of prevention until a client is in remission from drinking," says Selby. He adds that the role of nurses and midwives should be explored further as providing the opportunity for "multiple points of asking about alcohol use." This way, no care provider assumes that someone else in the chain of care has asked about alcohol use. And clients may be more comfortable discussing the issue with one care provider over another.

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