The following was a Telehealth Presentation offered on March 28, 2007 originating in Saskatoon, Saskatchewan. Speaker: Dr. Peter Selby Please click here to see the PowerPoint presentation of the Clinical Approaches to the Assessment of Alcohol Use in Pregnancy. Please click here to see the Alcohol Risk Assessment Professional's Manual.
Please click here to see the Alcohol T-ACE Screening Tool Card.
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That is common everywhere, both in
Canada and Internationally. It also occurs with smoking in pregnancy;
we hear "my doctor told me not to try to quit smoking in pregnancy
because it would be too stressful for me". Unfortunately there is no
statement in any formal textbook regarding zero tolerance for alcohol
use in pregnancy, and it may be that the patient is stating what she
wanted the physician to say. This is discussed in what is called the
"reasons model". This states that people are faced with challenges to a
behavior which is incongruent with health or social acceptability, they
have to create reasons to justify that behavior when it is questioned.
They may choose to state that they read information in a newspaper
article, or in this situation, particularly in an interview with a
nurse, that their doctor told them there was no reason to quit; In
effect "trumping" the nurse's advice. This is an interesting line of
research into the way people defend their behaviors. That is one aspect.
Another aspect is that there are healthcare professionals who continue
to give misleading information, so how do we deal with this? The answer
is education programs such as this. Healthcare professionals must
understand that we are talking about risk. The odds of having harm is
greater if the patient drinks alcohol than if they don't so health
professionals must consider what kinds of risk they wish their
patient's to take. This can be a difficult concept for patients to
grasp. In a city environment, when talking to a patient, I use the
analogy that there is risk in everyday life so what kind of risk do you
take? Are you the kind of person who only crosses the street at a
crossing light? That behavior increases your chance of crossing the
road safely; however, there is no absolute guarantee. Are you the kind
of person who runs in to the middle of the street against the traffic?
Eight times out of ten you may make it safely across but two times out
of ten you may not. In Northern communities I talk about taking a
skidoo out on the ice in the Spring. Most times you may cross the lake
safely but there is a much higher risk in this situation that you will
not. In education programs like this, information is spread to
healthcare professionals in attendance. We hope that these healthcare
professionals will spread the information to their peers and therefore
healthcare professionals will develop peer guidelines for management of
alcohol use in pregnancy.
The other important aspect is that there is no known benefit from
taking alcohol in pregnancy, so why take the risk of harm which cannot
be reversed?
The stigma of alcohol use can indeed act against disclosure so it's
important to create a context for disclosure during screening. Try to
make the screening setting comfortable and a safe place for discussion
of drinking and the patient's difficulties with alcohol so that this
can be discussed in a non-judgmental setting.
Asking the question "how much do you drink" rather than "do you drink"
is a good way to start. You can also ask, "when was the last time you
drank beer, wine, spirits, etc.?" Also indicate that you ask all women
in this situation about their alcohol consumption in the last thirty
days. Always keep in mind that there may be some intergenerational
risk, that is the patient themselves may have been alcohol exposed by
their own mothers or may be drinking to mask depression. If available
in your community anonymous testing of meconium may give a true
prevalence of substance usage in any given population.
We talk about the spontaneous rate of miscarriage in the first
trimester primarily due to poor development. We say that one in four
women who get pregnant will miscarry just because the sperm and egg do
not get together correctly and this is the body's natural way of
dealing with this. So, whether or not you drink, this can happen.
Because one of the things that happens to a woman who has taken alcohol
before she realizes she is pregnant is that she will connect any
adverse outcome to that alcohol use whether or not it is a correct
attribution. Also, three to five percent of pregnancies will have a
birth defect and we can't always relate this to drinking at critical
times in any pregnancy, but if you avoid alcohol for the rest of the
pregnancy you can avoid many of the brain development defects, which
can occur at any stage in the pregnancy. The chances (not the absolute
underlying effect) are that your child will not be further affected.
The other route for support is to refer the patient to Mother Risk by
telephone.
Of course in this situation the worst case scenario is that the patient
elects for a termination based on fear and not on evidence.
The origins of my work with this was with the Ontario "Best Start"
program. We had a project in which we developed materials then asked
communities to identify key opinion leaders in health professions and
brought them in to a Train the Trainer workshop, with the proviso that
they would return to their communities to help other health
professionals be supportive and to establish capacity for patient
support.
At last count the 20 original health professionals have trained 500
others using Grand Rounds and community education as tools.
In Ontario, and maybe in Saskatchewan, health professionals and
professional agencies are often isolated from community agencies who
share the same goals so we need to build bridges between us.
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