Importance of social support in preventing alcohol-exposed pregnancies with American Indian communities

The Elephant in the Room: A Systematic Review of the Application and Effects of Psychological Treatments for Pregnant Women with Dual Pathology (Mental Health and Substance-Related Disorders)

PURPOSE

Maternal mental health and substance use, referred to as dual pathology, represent significant concerns associated with adverse pregnancy and birth outcomes, a prevalence higher than commonly anticipated. Nonetheless, a notable dearth exists ofevidence-based treatment protocols tailored for pregnant women with dual pathology.

METHODS

A systematic review, adhering to the PRISMA methodology, was conducted.

RESULTS

Out of the 57 identified papers deemed potentially relevant, only 2were ultimately included. Given the limited number of studies assessing the efficacy of psychological interventions utilizing randomized controlled trials (RCTs) for both mental health and substance misuse, and considering the diverse objectives and measures employed, definitive conclusions regarding the effectiveness of psychological interventions in this domain prove challenging.

CONCLUSIONS

Maternal mental health appears to be the proverbial "elephant in the room". The development of specialized and integrated interventions stands as an imperative to effectively address this pressing issue. As elucidated in the present review, these interventions ought to be grounded in empirical evidence. Furthermore, it is essential that such interventions undergo rigorous evaluation through RCTs to ascertain their efficacy levels. Ultimately, the provision of these interventions by psychology/psychiatric professionals, both within clinical practice and the RCTs themselves, is recommended to facilitate the generalizability of the results to specialized settings.

Prenatal Alcohol Counseling Among American Indian and Alaska Native Women and Non-Hispanic White Women in the Pregnancy Risk Assessment Monitoring System

OBJECTIVE

Universal screening and counseling are recommended for alcohol use during pregnancy, but no prior study has examined differences in prenatal counseling by race or ethnicity. We used Pregnancy Risk Assessment Monitoring System (PRAMS) data to assess differences in provision of counseling on prenatal alcohol use between American Indian/Alaska Native (AI/AN) and non-Hispanic White (NHW) women during prenatal care.

METHODS

We analyzed data from 2014-2015 from the four PRAMS states with the highest number of births to AI/AN women: Alaska, New Mexico, Oklahoma, and Washington. We estimated the prevalence of prenatal alcohol use, associated risk factors, and prenatal alcohol prevention counseling for AI/AN (n = 1,805) and NHW (n = 5,641) women. We then conducted multivariable logistic regression modeling stratified by race to estimate factors associated with receipt of prenatal alcohol prevention counseling. All analyses were weighted and accounted for the complex sampling design of PRAMS.

RESULTS

Results showed that AI/AN women were counseled on prenatal alcohol use more often than NHW women (77% vs. 67%, p < .05), although the likelihood of any prenatal alcohol use was the same in both groups. The likelihood of prenatal drinking increased with age, education, and income in both groups. Higher education levels were significantly associated with lower risk of prenatal alcohol counseling receipt among AI/AN women. Compared with those with less than a high school diploma, AI/AN women with a college degree or more had 39% reduced risk of receiving counseling (adjusted risk ratio [aRR] = 0.61; 95% confidence interval [CI]: 0.45-0.83). Among NHW women, living at 100% to 199% of the Federal Poverty Level was associated with lower risk (aRR = 0.88; 95% CI: 0.79-0.98) of counseling receipt compared with women living below the federal poverty line. Higher parity was significantly associated with lower risk of counseling for both groups of women.

CONCLUSION

Although race was not associated with prenatal alcohol use, AI/AN women were more likely than NHW women to be counseled about prenatal alcohol exposure. Factors associated with counseling receipt differed between the two groups. These findings suggest that receipt of counseling is associated with sociodemographic characteristics, and that counseling is not universally provided. More efforts to provide universal counseling are warranted.

Prevention of alcohol related harm though preconception care: A scoping review of barriers and enablers

Objective

To understand the perspectives of healthcare practitioners and women of reproductive age regarding addressing prevention of an alcohol exposed pregnancy before conception.

Methods

A scoping review of mixed methods, qualitative and quantitative research was conducted. Medline, CINAHL, EMBASE and PsychInfo databases were searched for literature published by March 2022. Data were extracted and synthesized.

Results

Twenty-three studies were included. Views varied between healthcare practitioners and women about addressing alcohol with women before pregnancy. Healthcare practitioners agreed prevention was important but believed they were ill-prepared to provide support, and that it might be intrusive if women were not contemplating pregnancy. Whereas women would welcome advice from healthcare practitioners, particularly if offered during appointments or visits for services related to reproductive health. A knowledge deficit about pregnancy and fetal harms from alcohol was expressed by both healthcare practitioners and women.

Conclusions

Investment in alcohol education and skills training for healthcare professionals is required to ensure a coherent message is communicated across services, and that shared decision making about healthcare between service users and health professionals is facilitated. Future research should explore implementation of interventions to prevent alcohol exposed pregnancy in settings where women are seeking reproductive health support.

Substance Use Disorders in Global Mental Health Delivery: Epidemiology, Treatment Gap, and Implementation of Evidence-Based Treatments

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Assess the treatment gap for patients with substance use disorders• Evaluate treatments and models of implementation for substance use disorders ABSTRACT: Substance use disorders (SUDs) account for substantial global morbidity, mortality, and financial and social burden, yet the majority of those suffering with SUDs in both low- and middle-income (LMICs) and high-income countries (HICs) never receive SUD treatment. Evidence-based SUD treatments are available, but access to treatment is severely limited. Stigma and legal discrimination against persons with SUDs continue to hinder public understanding of SUDs as treatable health conditions, and to impede global health efforts to improve treatment access and to reduce SUD prevalence and costs. Implementing SUD treatment in LMICs and HICs requires developing workforce capacity for treatment delivery. Capacity building is optimized when clinical expertise is partnered with regional community stakeholders and government in the context of a unified strategy to expand SUD treatment services. Workforce expansion for SUD treatment delivery harnesses community stakeholders to participate actively as family and peer supports, and as trained lay health workers. Longitudinal supervision of the workforce and appropriate incentives for service are required components of a sustainable, community-based model for SUD treatment. Implementation would benefit from research investigating the most effective and culturally adaptable models that can be delivered in diverse settings.

Pre-pregnancy and Prenatal Alcohol use Among American Indian and Alaska Native and Non-Hispanic White Women: Findings from PRAMS in Five States

INTRODUCTION

Estimates of prenatal alcohol use among American Indian and Alaska Native (AI/AN) women are limited. This study sought to characterize pre-pregnancy and prenatal alcohol use among AI/AN women in the Pregnancy Risk Assessment Monitoring System (PRAMS) dataset, evaluate variation in alcohol use by state and rural/urban residence, and evaluate associations between potential risk factors and prenatal alcohol use among AI/AN and non-Hispanic white (NHW) women.

METHODS

We pooled PRAMS data from five states (Alaska, New Mexico, Oklahoma, South Dakota and Washington) from 2015 to 2017. We estimated the prevalence of pre-pregnancy and pregnancy risk factors, and alcohol use by race and examined alcohol use by state and rural/urban residence among AI/AN women. We conducted bivariate and multivariable logistic regression modelling to estimate the association between each risk factor of interest and the odds of prenatal alcohol use for AI/AN and NHW women.

RESULTS

AI/AN women were less likely to report pre-pregnancy alcohol use compared to NHW women (56% vs. 76%, p < 0.0001). Among women who reported drinking pre-pregnancy, AI/AN women were more likely than NHW women to report drinking 1 or more drinks during pregnancy (4.3% vs. 2.4, p = 0.0049). For AI/AN women, older age and experiencing homelessness (aOR = 2.76; 95% CI 1.16-6.55) increased odds of prenatal alcohol use. For NHW women, having a college education (aOR = 4.06; 95% CI 1.19-13.88) and urban residence (aOR = 1.88; 95% CI 1.40-2.53) increased odds of prenatal alcohol use.

CONCLUSIONS

Factors associated with prenatal alcohol use differ between AI/AN women and NHW women, suggesting the need for tailored interventions.

Exploring the contributions and suitability of relational and community-centered fetal alcohol spectrum disorder (FASD) prevention work in First Nation communities

BACKGROUND

This study provides initial evidence of the contributions and suitability of relational, trauma-informed, and community-based approaches for programs aimed at the prevention of future alcohol-and drug-exposed births. Specifically, this study extends understanding of the experiences of mentors providing evidence-based 3-year home visitation services through the Parent-Child Assistance Program (PCAP) in rural and isolated First Nation communities in Alberta, Canada.

METHODS

Using a participatory approach to this research project, we explored existing PCAP services to capture implementation across six rural and isolated Alberta fetal alcohol spectrum disorder (FASD) networks involving First Nation communities over an 8-month period. In total, we generated qualitative data with 35 participants to examine mentors' perceptions of the impacts and suitability of a relational, trauma-informed, and community-based approach to service delivery.

RESULTS

Six major themes were revealed from the thematic analysis as key mechanisms of culturally responsive program delivery across the six FASD networks.

CONCLUSIONS

Relational, trauma-informed, and community-centered FASD prevention programming was perceived to have positive impacts and be well suited for use within Indigenous communities, and allow for service delivery to be locally and culturally responsive.

"But Problems Dwell so the Urge Is Constant…" Qualitative Data Analysis of the OST CHOICES Program

BACKGROUND

Fetal alcohol spectrum disorders are a major public health concern including among American Indian (AI)/Alaska Native (AN) communities. Various studies have demonstrated higher alcohol consumption among AI/AN women during pregnancy compared with other groups. This study intends to understand the milieu within which such consumption patterns flourish. The study utilizes qualitative and quantitative data from the Oglala Sioux Tribe (OST) CHOICES Program, a tribally run public health program that aims to reduce alcohol-exposed pregnancy preconceptually in AI women.

METHODS

Alcohol consumption pattern (n = 264) is analyzed using descriptive statistics. Consumption patterns included average drinks consumed daily, their choice of drinks (beer, whiskey, wine, etc.), how much money participants were spending on alcohol and amount of calories consumed from alcohol. Qualitative data analysis included open coding of data from decisional balance exercise of the CHOICES program that looked at good things and not so good things about participants' drinking.

RESULTS

Women reported drinking an average of 12 drinks daily, ranging between 1 and 86. Women drinking at home spent a median of $4,320 and $12,960 if drinking at a bar. A median of 1,200 calories per day from alcohol was reported. More women reported drinking beer compared with other types of alcohol within a domestic setting. Qualitative data analysis identified positive and negative aspects of drinking among the participants of OST CHOICES Program. Positive aspects included escaping from problems, socializing, and relaxation. Negative aspects included impact on families and domestic violence.

CONCLUSIONS

While understanding their milieu, our study also unraveled different struggles (such as violence, peer pressure, financial burden, and depression) encountered by Native women in their daily lives. According to the participants, positive aspects of drinking outweigh the negative aspects and they viewed their drinking as a solution and not a problem.

Online scan of FASD prevention and health promotion resources for Aboriginal and Torres Strait Islander communities

ISSUE ADDRESSED

Foetal Alcohol Spectrum Disorder (FASD) includes a range of life-long impairments caused by alcohol exposure in utero. Health professionals are vital to preventing FASD but many are hesitant to discuss FASD with clients due to their need for additional resources to aid the conversation. This scan sought to identify the scope and gaps in publicly available FASD prevention and health promotion resources, and assess their cultural appropriateness for use among five key groups of Indigenous Australian people including: (i) pregnant women, (ii) women of childbearing age, (iii) grandmothers and aunties, (iv) men, and (v) health professionals.

METHODS

Relevant resources published 1995-2017 were identified through the Australian Indigenous HealthInfoNet, FASD organisation websites, grey literature, Google searches, and field experts. Results were screened by inclusion and cultural appropriateness criteria developed and piloted by the research team, and further screened by health professionals attending FASD training workshops.

RESULTS

115 of the 2146 identified resources were eligible. Relevant resources were found for all five key groups; however, no resources were specifically designed for men, grandmothers or aunties.

CONCLUSIONS

A range of high-quality, culturally appropriate resources were identified, however, health professionals attending the training workshops were not aware of their availability. Further resource development is suggested for men, grandmothers and aunties. SO WHAT?: Prioritisation of active dissemination and implementation strategies is suggested to increase awareness and use of future resource developments. The inclusion of a resource trial among health professionals is a recommended strategy to increase awareness and use of newly developed resources.

The Oglala Sioux Tribe CHOICES Program: Modifying an Existing Alcohol-Exposed Pregnancy Intervention for Use in an American Indian Community

Alcohol-exposed pregnancies are a health issue for many American Indian communities. The goal of this manuscript is to outline how an existing alcohol-exposed pregnancy prevention program with non-pregnant women (Project CHOICES) was modified to fit the needs and norms of an American Indian community. The Oglala Sioux Tribe CHOICES Program was developed and implemented using community feedback through initial meetings, reviewing materials, gathering input into recruitment and intervention logistics, and conducting interviews to evaluate the program. The intervention was implemented and has been enrolling non-pregnant American Indian women for the past several years. While data collection is ongoing, it has shown preliminary success in changing behaviors and in impacting how the community views the prevention of alcohol-exposed pregnancies. Overall, this study highlights the potential to expand this prevention program to other sites and with other populations, such as adolescents. By the end of this article, readers will comprehend the steps necessary to replicate such a program at other tribal and rural sites.

Substance Use in the Perinatal Period

Perinatal substance use remains a major public health problem and is associated with a number of deleterious maternal and fetal effects. Polysubstance use in pregnancy is common and can potentiate adverse maternal and fetal outcomes. Tobacco is the most commonly used substance in pregnancy, followed by alcohol and illicit substances. The treatments for perinatal substance use are limited and consist mostly of behavioral and psychosocial interventions. Of these, contingency management has shown the most efficacy. More recently, novel interventions such as progesterone for postpartum cocaine use have shown promise. The purpose of this review is to examine the recent literature on the use of tobacco, alcohol, cannabis, stimulants, and opioids in the perinatal period, their effects on maternal and fetal health, and current treatments.

Development and Implementation of CHOICES Group to Reduce Drinking, Improve Contraception, and Prevent Alcohol-Exposed Pregnancies in American Indian Women

Public health officials assert that prevention of alcohol-exposed pregnancies (AEP) should begin before conception, by reducing alcohol consumption in women at-risk for or planning pregnancy, and/or preventing pregnancy in women who are drinking at risky levels. One such effort is the Oglala Sioux Tribe (OST) CHOICES Program. While the OST CHOICES Program has been successfully implemented, a community-based needs assessment determined that the OST CHOICES intervention should expand and be delivered in a group setting using group motivational interviewing (MI) techniques. After extensive group MI and CHOICES group trainings, recruitment for CHOICES Group began and within a ten month period, a total of twelve groups with non-pregnant American Indian women were held for this pilot intervention. Evaluations completed by participants indicated that CHOICES Group sessions positively engaged members, had low levels of anger or tension, and had average levels of avoidance of personal responsibility. An evaluation of the CHOICES Group leaders indicated strengths in certain MI skills, although improvement is needed in some core MI and group leadership skills. This is an important expansion of a successful AEP prevention program (CHOICES), as well as a novel application of MI, and recommendations and future plans for this intervention are outlined.