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Do Canadian prenatal record forms integrate evidence-based guidelines for the diagnosis of a FASD?

Maternal alcohol use during pregnancy can have a devastating lifelong impact on the developing fetus. Fetal Alcohol Spectrum Disorder (FASD) refers to Fetal Alcohol Syndrome (FAS) and all other diagnoses (e.g., Fetal Alcohol Effects (FAE), Partial Fetal Alcohol Syndrome) which define the continuum of effects caused by prenatal exposure to alcohol. (1) FAS represents the most severe spectrum of preventable disabilities and is characterized by growth deficiency, dysmorphology, and a complex pattern of behavioural and cognitive difficulties. (2-4) Prevalence rates of FASD reported in the literature, which includes the diagnosis of FAS, are mere estimates and vary based on methods used, for instance, passive surveillance, clinic-based studies, and active case ascertainment. (5) The Canadian prevalence rate for a FASD is believed to be about 9 per 1000 with an estimated 3,000 babies being born each year with a FASD. (6) Higher rates of full FAS have been reported among the offspring of chronically alcoholic women (25 per 10,000), (7) and the rate of FAS across isolated North American Aboriginal populations may vary up to 100-fold. (8,9)

Prenatal alcohol exposure exacts a heavy burden of psychological, emotional and financial costs to the affected individual, their caregivers and society. (10-13) The estimated direct costs and productivity losses for an individual with FAS/FAE from birth to 65 years is $844,066. (14) Given a rate of 1 FASD case per 100 pregnancies, the annual cost of FASD is estimated at $4 billion. (15)

In 2005, a pan-Canadian FASD initiative, undertaken by the Public Health Agency of Canada and Health Canada's First Nations and Inuit Health Branch, developed Canadian guidelines to promote a uniform approach to screening, diagnosing and reporting a FASD. (16) All Canadian provinces and territories require prenatal care providers to use standardized, government-issued prenatal record forms to ensure systematic monitoring and documentation of health risk factors during routine prenatal care. Integration of the FASD Canadian guidelines into provincial prenatal records across Canada could help facilitate population-wide surveillance of high-risk drinking behaviour during pregnancy, referral for appropriate counseling and treatment, and early diagnosis of a FASD. The purpose of this study was to appraise the extent to which prenatal record forms from different provinces and territories currently reflect recommendations related to alcohol use screening, exposure assessment, intervention and referral endorsed in the Canadian guidelines for the diagnosis of FASD.

METHODS

In late 2007, prenatal record forms were obtained from each of Canada's 10 provinces and 3 territories through health authorities or other professional contacts. One province (British Columbia) and territory (Yukon) shared the same prenatal record form, for a total of 12 different prenatal record forms. All written items (e.g., assessment questions, intervention prompts, instruction guides) related to screening, exposure assessment or interventions for maternal alcohol use were extracted from each prenatal record form, categorized and compared across provinces/territories. The extracted items were evaluated for their coherence with evidence-based recommendations drawn from the Canadian guidelines for diagnosis of a FASD and the broader FASD literature. Three recommendations are not explicitly stated in the Canadian guidelines but are strongly supported by evidence, namely screening for prepregnancy use of alcohol; assessing exposure by inquiring about alcohol quit date; and referring a pregnant client who drinks during pregnancy to appropriate counseling and treatment. The specific recommendations examined and their supporting literature are summarized in Appendix 1. All data were extracted and evaluated by the first author (SP) and findings were double-checked for accuracy by a research assistant and the second author (SS).

RESULTS

Revision dates for the prenatal record forms ranged from 2000 to 2007; two forms did not indicate their latest date of revision. Items on the forms related to screening, exposure assessment, and/or intervention for maternal alcohol use varied markedly across provinces and territories. Findings are summarized in Table 1.

Prenatal screening for maternal alcohol use

To gather reliable information about alcohol exposure during pregnancy, the Canadian guidelines assert that health care providers must inquire about alcohol use prior to pregnancy recognition. (16) Only 2 of the 12 prenatal record forms (13%) specifically queried about pre-pregnancy alcohol use, using wording such as "before pregnancy". One of these forms (NL) prompted a simple "yes" or "no" response, whereas the other (BC) inquired about additional dimensions of pre-pregnancy alcohol consumption (e.g., average volume of consumption). One prenatal record form (AB) does not directly query about pre-pregnancy alcohol use but is accompanied by a questionnaire to facilitate data collection which links to the form. In this questionnaire, women are asked about drinks per week, number of drinks per day, and number of drinks per month in relation to "before I knew I was pregnant".

According to the Canadian guidelines, all pregnant women should be screened for alcohol use using validated screening tools such as the T-ACE (tolerance, annoyed, cut-down, eye-opener) or TWEAK (tolerance, worry, eye-opener, amnesia, cut-down). (15) However, only 5 prenatal record forms (41%) included a validated screening tool to identify risk drinking during pregnancy as part of their screening questions (MB, NL, NWT, PEI) or in an accompanying guide on prenatal assessment (BC). Of these, 4 prenatal record forms used the T-ACE or a modified version of the T-ACE and 1 used the TWEAK. Four of these five prenatal record forms provided a check box for the prenatal care provider to record the risk score derived from the screening tool.

The Canadian guidelines also recommend that health care professionals screen for additional factors that may predict alcohol-exposed pregnancy. (16) All the prenatal record forms contained questions assessing known predictors of maternal alcohol use such as maternal age, previous history of prenatal drug or alcohol use, access to prenatal care, and significant psychosocial stressors. Four forms (33%) contained an antenatal risk assessment score that included alcohol use as a risk factor in the pregnancy profile. Three prenatal record forms (25%) included supplemental questionnaires that provide a more in-depth assessment of psychosocial issues.

Assessment of alcohol exposure

As the single most important risk factor for FASD is high blood-alcohol concentration, optimal screening for prenatal maternal alcohol use should involve a comprehensive assessment of fetal alcohol exposure including duration of exposure (i.e., total days exposed), dose or magnitude of exposure, and the cumulative dose (i.e., total drinks during pregnancy). (16-20) Accordingly, the Canadian guidelines recommend assessment and documentation of the amount and type(s) of alcoholic drinks consumed, the pattern of drinking, the frequency of drinking, and the quit date in the maternal history. All 12 prenatal record forms included at least one question about maternal alcohol consumption. However, there were considerable differences in the format, wording, and number of items related to the different dimensions of alcohol consumption assessed (e.g., average volume of consumption and patterns of drinking). For instance, 6 prenatal record forms (50%) additionally inquired about quantity of alcohol used per drinking episode and 3 forms (25%) included questions about the frequency of alcohol use (e.g., "how many days a week do you consume alcohol?"). Questions related to quantity and frequency of alcohol use were predominantly open-ended with only 1 form (AB) providing ordered response choices. Just 3 prenatal record forms (16%) assessed the drinking pattern either by asking specifically about binge drinking (BC), including the question "how often do you have 3 or more drinks per day?" (AB), or by directing the prenatal care provider to "query patterns of alcohol usage" (NU). None of the prenatal record forms guided prenatal care providers to inquire about the type(s) of alcoholic drinks consumed. Only 2 of the 12 prenatal record forms (17%) were designed to prompt the prenatal care provider to reassess for alcohol use over the course of pregnancy (BC, NWT). Finally, only 3 of the prenatal record forms (25%) contained items assessing whether and when the woman stopped drinking during their pregnancy, using either a check box indicating "quit" (AB, MB) and/or querying the exact day/month/year of the "quit date" (BC).

Key to establishing an accurate diagnosis of a FASD is confirmation of prenatal maternal alcohol consumption via documentation of the source of information (e.g., reliable clinical observation, maternal self-report, medical records, or other social, legal or medical problems related to drinking during pregnancy). (16) None of the prenatal record forms required the prenatal care provider to document the data sources for their assessment of maternal risk behaviour for alcohol exposure during pregnancy.

Intervention and referral

Given inconsistent findings with regards to adverse effects of low to moderate alcohol use during pregnancy, the axiom no amount of alcohol is considered safe during pregnancy is not universally accepted. (21) However, the Canadian guidelines recommend that health care providers advocate abstinence from alcohol during pregnancy to all women. (16) Seven prenatal record forms (58%) listed alcohol use as a potential discussion topic during prenatal care visits, but provided no written prompts to advise abstinence from alcohol throughout the pregnancy. However, 2 forms (MB, PEI) (16%) included an algorithm to screen for alcohol use that instructs the prenatal care provider to "promote zero tolerance for alcohol when planning or during pregnancy" for clients who responded "no" to the question "do you use alcohol?" (i.e., low-risk women).

All pregnant women identified as at risk for heavy alcohol use should receive early brief intervention or be referred for appropriate counseling and treatment to improve outcomes for the mother and baby. (16) Only 3 prenatal record forms (25%) specifically prompted the prenatal care provider to intervene for maternal risk drinking, following risk classification for heavy alcohol using an antenatal risk assessment score or a screening tool for alcohol use such as the T-ACE (MB, NL, PEI). Two of these forms (MB, PEI) embed a "screening for alcohol use" algorithm that guides the referral process, prompting urgent referral to specialized resources for high-risk mothers and brief interventions for the mothers deemed 'at risk.' Of note, none of the 12 prenatal record forms specifically prompted the prenatal care provider to refer the child of the index pregnancy or their sibling(s) for FASD screening and diagnosis when there was evidence of significant fetal exposure to alcohol.

DISCUSSION

All the provincial/territorial prenatal record forms examined in this study met the Canadian guidelines' recommendation to ask all pregnant women whether or not they drink alcohol during pregnancy. The most recent data from the Canadian Community Health Survey indicate that although rates of maternal alcohol use are declining, 11% of Canadian mothers surveyed in 2005 reported drinking during pregnancy, with regional rates ranging from 4% (NL) to 18% (QC) (22) (Table 2). Therefore it is particularly important that prenatal record forms across provinces and territories continue to adhere to this recommendation. A randomized controlled trial of brief intervention for prenatal alcohol use reported an overall decline in consumption of alcohol, even among the control group women who only received an assessment of alcohol use. (23) Such potential behaviour change simply from the effect of being assessed for alcohol exposure underscores the importance of asking all pregnant women about their history of alcohol use before and during pregnancy.

All provincial and territorial prenatal record forms included items screening for one or more interrelated health or lifestyle factors predictive of higher alcohol consumption during pregnancy. However, their interrelationships and interactive effects may not be appreciated by prenatal care providers if these items are not specifically linked together on the prenatal record forms. Prenatal care providers unfamiliar with issues of FASD are less likely to undertake a comprehensive review of alcohol exposure risk factors (24) or use their assessment of key predictors to determine risk for alcohol consumption and appropriately intervene.

A minority of the prenatal record forms specifically queried prepregnancy alcohol use or when the woman stopped drinking during pregnancy. Since pregnancy recognition may not occur until at least five weeks of pregnancy, (25) women who binge drink before pregnancy recognition (26) may remain unrecognized as carrying a fetus at risk for alcohol exposure.

Determination of level of risk drinking during pregnancy is likely being underestimated across Canada as less than half of the prenatal record forms include a validated screening tool such as the T-ACE or TWEAK to identify risk drinking during pregnancy. Most of the prenatal records examined did not include questions related to amount and type(s) of alcoholic drinks consumed, the pattern of drinking, or the frequency of maternal drinking to determine the level of risk drinking during pregnancy. Furthermore, they did not include prompts to encourage prenatal care providers to intervene or refer clients with identified or suspected high-risk drinking behaviour. Failure to identify risk drinking during pregnancy or to appropriately intervene may increase the affliction of disability to the alcohol-exposed fetus. Pregnancy has been identified as an opportune "teachable moment" to adopt risk-reducing health behaviours such as reduction or abstinence from alcohol, to improve maternal health and protect the well-being of the fetus. (27,28) Early detection of maternal alcohol consumption during pregnancy through screening and engaging women who are not dependent on alcohol in drinking reduction or abstinence and referring women who are dependent on alcohol to specialized treatment programs may substantially reduce the risk of a FASD. (29,30)

The study findings indicate that current evidence-based recommendations related to the prevention and diagnosis of FASD have not been consistently integrated into prenatal record forms across Canadian provinces and territories. Research currently underway has revealed that the participants and processes involved in the revision of prenatal record forms vary considerably across Canadian jurisdictions, and the inclusion (or not) of specific prenatal screening questions may be influenced by such diverse factors as feasibility, cost or population needs. (31) More information about contextual factors such as provincial rates of maternal risk drinking and FASD, marketing of alcohol, and the presence or influence of provincial FASD committees is needed to better understand the uptake of research evidence related to screening and interventions for maternal alcohol consumption into provincial/territorial prenatal record forms.

Simple changes to the prenatal record, such as inclusion of an alcohol screening tool, may facilitate population-wide identification for prenatal alcohol exposure and implementation of strategies to promote risk-reducing health behaviours. The Canadian Medical Association has recently resolved to develop a standardized national prenatal form, (32) providing a window of opportunity to harmonize the content in provincial and territorial prenatal record forms with respect to evidence-based recommendations set forth in the Canadian guidelines and the FASD literature. A consensus report recently approved by the FASD Advisory workgroup (33) offers additional direction for the adoption of a standardized screening process and universal questions to include in the prenatal records. Empirical research is needed to identify optimal strategies to promote integration of the Canadian guidelines into standardized prenatal records, as well as to evaluate the impact of the use of these new standardized prenatal records on improving the health and well-being of both the mother and the unborn child.
Appendix 1. Evidence-based Recommendations for Screening of Alcohol
Use, Exposure Assessment, and Intervention or Referral for Maternal
Alcohol Use in Canada

Evidence-based             Comments/Recommendations in the Canadian
Practices                  Guidelines

Prenatal Screening for
Maternal Alcohol Use

Screen for                 Comment: "Special attention must be paid
pre-pregnancy use          to inquiring about maternal alcohol use
of ETOH                    before the woman recognized that she was
                           pregnant. Some women do not consider that
                           their prior drinking is important and many
                           underreport it". (16), p.S11

To identify risk           Recommendation 1.1: "All pregnant and
drinking, use validated    post-partum women should be screened
screening tool such as:    for alcohol use with validated screening
* T-ACE                    tools (i.e., T-ACE, TWEAK) by relevant
* TWEAK                    health care providers". (16), p.S4

                           Comment: "There is moderate evidence to
                           support the use of T-ACE and TWEAK to
                           identify women who would benefit from
                           intervention for alcohol use during
                           pregnancy". (16), p.S6

Screen for one or          Recommendation 5.3: "Hearsay, lifestyle,
more interrelated          other drug use  or history of alcohol
risk factors which         exposure in previous pregnancies cannot,
predict alcohol            in isolation, be informative of drinking
consumption during         patterns in the index pregnancy. However,
pregnancy                  co-occurring disorders, significant
                           psychosocial stressors and prenatal
                           exposure to other substances (e.g.,
                           smoking, licit or illicit drugs) in the
                           index and previous pregnancies should still
                           be recorded, based on known interactive
                           effects of these variables on the severity
                           of pregnancy outcomes for both the mother
                           and her offspring". (16), p.S11

Assessment of Alcohol      Comment: High blood-alcohol concentration
Exposure Average volume    is the most significant risk factor
(i.e., quantity) of        influencing the potential impact maternal
alcohol consumption        alcohol consumption may have on the
                           fetus. (16)

                           Recommendation 5.2: "The number and type(s)
                           of alcoholic beverages consumed (dose), the
                           pattern of drinking and the frequency of
                           drinking should all be documented if
                           available". (16), p.S11

Type(s) of alcohol and     Recommendation 5.2: Same as above. (16),
drink size                 p.S11

Patterns of drinking       Recommendation 5.2: Same as above. (16),
(i.e., binge)              p.S11
and frequency
(i.e., daily)

ETOH quit date             Comment: "Stopping drinking at any time
                           during pregnancy will reduce risk of
                           adverse effects of prenatal alcohol
                           exposure". (16), p. S6

Document and confirm       Recommendation 5.1: "Prenatal alcohol
risk for prenatal          exposure requires confirmation of alcohol
alcohol exposure           consumption by the mother during the index
                           pregnancy based on reliable clinical
                           observation, self-report, reports by a
                           reliable resource or medical records
                           documenting positive blood alcohol, alcohol
                           treatment or other social, legal or medical
                           problems related to drinking during
                           pregnancy". (16), p.S11

                           Comment: "Often women will not accurately
                           recall the amount or frequency of alcohol
                           consumption during pregnancy. Some women
                           may also underestimate consumption level
                           or deny that they drank alcohol during
                           pregnancy. Medical records are known to
                           be incomplete with respect to maternal
                           alcohol history". (16), p.S15

Intervention and           Recommendation 1.2: "Abstinence should be
Referral Advocate          recommended to all women during pregnancy,
abstinence                 as the mother's continued drinking during
                           pregnancy will put the fetus at risk for
                           effects related to prenatal alcohol
                           exposure". (16), p.S4

Offer early, brief         Recommendation 1.1: Women at risk for heavy
intervention               alcohol use should receive early brief
                           intervention (i.e., counseling). (16), p.S4

Refer pregnant client      Comment: "The purpose of screening should
who drinks during          be to facilitate referral to a diagnostic
pregnancy                  clinic and highlight the need for referral
                           and support for the birth mother". (16),
                           p.S6

Evidence-based             Supporting Literature
Practices

Prenatal Screening for
Maternal Alcohol Use

Screen for                 Approximately one third to half of all
pre-pregnancy use          pregnancies are not planned. (26) Among
of ETOH                    those not planning a pregnancy, alcohol
                           use is higher during pre-pregnancy
                           recognition. (26) At pregnancy recognition,
                           a majority of women change their pattern of
                           drinking. (34) However, this may not occur
                           until five weeks of pregnancy, (25) putting
                           the fetus at risk for exposure during the
                           early stages of embryonic development. (26)

To identify risk           Given the stigma associated with maternal
drinking, use validated    alcohol consumption, pregnant women may
screening tool such as:    deny alcohol use or underreport the
* T-ACE                    quantity or frequency of alcohol consumed.
* TWEAK                    (34,35) The T-ACE scale offers the best
                           balance of sensitivity and specificity for
                           identifying alcohol use among diverse groups
                           of pregnant women. (35-38) The TWEAK has
                           performed better than other screening tools
                           in identifying women with alcohol abuse
                           or dependence (36) and shows promise in
                           identifying risk drinking during pregnancy.
                           (39) Women, regardless of race or economic
                           status, should be screened to identify risk
                           behaviours related to alcohol use and
                           receive early brief intervention to improve
                           their own health status as well as that of
                           their unborn child. (40)

Screen for one or          Identification of risk factors associated
more interrelated          with alcohol consumption may help to
risk factors which         improve the detection of alcohol use during
predict alcohol            pregnancy. In the review of literature
consumption during         included in the Canadian guidelines, risk
pregnancy                  factors for prenatal alcohol exposure
                           included higher maternal age, lower
                           educational level, prenatal exposure to
                           cocaine and smoking, custody changes,
                           lower socio-economic status, paternal
                           drinking and drug use at the time of
                           pregnancy, reduced access to prenatal and
                           postnatal care and services, inadequate
                           nutrition, poor developmental environment
                           (e.g., stress, abuse, neglect), untreated
                           or under-treated mental health concerns,
                           social isolation, and histories of severe
                           childhood sexual abuse. (16)
                           p.S1-S2Societal factors, such as loose
                           social organization or integration, (41,42)
                           may also influence patterns of drinking.
                           These factors, along with longstanding
                           nutritional and genetic factors, may
                           explain the seemingly higher incidence of
                           FAS within specific socio-economic
                           groups. (43,44)

Assessment of Alcohol      A dose-response relationship exists between
Exposure Average volume    prenatal alcohol exposure and growth.
(i.e., quantity) of        Growth deficit, a characteristic of FAS, is
alcohol consumption        directly related to the amount of alcohol
                           consumed. (45)

Type(s) of alcohol and     Alcohol content and drink size impact
drink size                 blood-alcohol concentration. (46) The
                           alcohol content depending on type of
                           alcohol beverage consumed can vary (46,47)
                           and range between 4.2% (e.g., beer) to 40%
                           (e.g., distilled spirits) alcohol by
                           volume. (46) Significant variation in drink
                           size, particularly for spirits and wine,
                           has been demonstrated with measures to
                           improve precision of alcohol intake (e.g.,
                           use of measured drinks). Among women,
                           monthly alcohol intake was reported to be
                           30.3% more with the use of measured
                           drinks. (46) Identification of drink size
                           facilitates identification of high-risk
                           drinkers and prevents misclassification of
                           binge drinkers. (46) The type of alcoholic
                           beverage should also be ascertained to
                           better estimate alcohol consumption and
                           identify high-risk drinkers. (46,48)

Patterns of drinking       Fetal blood alcohol concentration is
(i.e., binge)              related to many factors such as maternal
and frequency              patterns of alcohol consumption (e.g.,
(i.e., daily)              binge drinking--that is, four or more
                           drinks per occasion), and frequency of
                           alcohol use. (19,20) Binge drinking may be
                           more harmful than consuming the same
                           amount of alcohol spread over time49as the
                           fetus is exposed to considerably higher
                           peak blood alcohol concentrations during
                           binge drinking. (19) Assessment of patterns
                           of alcohol exposure should be
                           trimester-specific, as outcomes of fetus
                           will differ. For instance, alcohol
                           consumption in early pregnancy increases
                           the risk of having a low birthweight
                           infant. (45)

ETOH quit date             Same as above. Quit date potentially
                           provides information about alcohol intake
                           during the pregnancy pre-recognition
                           time period.

Document and confirm       Difficulties with diagnosing a FASD relates
risk for prenatal          to inaccurate and/or lack of information
alcohol exposure           about maternal alcohol use during
                           pregnancy. (50) Less than 1% of the medical
                           charts contain data that can be used to
                           determine alcohol use during pregnancy.
                           (18) In certain instances, discrepancies
                           are noted between information recorded in
                           the prenatal record forms, and medical
                           chart. (18) If information pertaining to
                           maternal history of alcohol use is clearly
                           documented and consistent information is
                           noted when reviewing the medical chart,
                           assessment for level of risk of exposure
                           would be confirmed. However, in the
                           majority of cases, documentation is poor.
                           (18) Prenatal records may not be completed
                           in their entirety or inconsistencies may
                           be identified when comparing various parts
                           of the maternal chart. Alternatively,
                           disparities may exist between the woman's
                           self-report (i.e., denies use) and clinical
                           observations or reports from the partner,
                           friend, or family member. In these
                           instances, level of risk of exposure would
                           be speculative. Some diagnosticians use
                           confirmed, unknown or absent prenatal
                           alcohol exposure as a way of
                           differentiating clinically meaningful
                           exposure to rank risk of
                           prenatal alcohol exposure. (50)

Intervention and           There is no "safe" level of alcohol intake
Referral Advocate          during pregnancy, as research findings are
abstinence                 equivocal when examining exposure to low to
                           moderate alcohol levels during pregnancy.
                           (45,47,51) Health Canada advises that women
                           who are or may become pregnant abstain from
                           alcohol use. FASD is preventable if women
                           abstain from consuming alcohol during
                           pregnancy. (45,47,52)

Offer early, brief         Brief interventions involve a time-limited
intervention               (e.g., 5-10 minutes) patient education and
                           self-help preventive strategy. Brief
                           interventions with women who screened
                           positive for mild to moderate drinking
                           problems during pregnancy have demonstrated
                           effectiveness in reducing alcohol use
                           pre- and postnatally, (23,39,53-57) and
                           improving neonatal outcomes. (57) Brief
                           intervention that includes partner
                           participation, as identified by the woman,
                           in the session may be effective for those
                           women who drink more prenatally. (23) The
                           cost-effectiveness of brief intervention
                           for pregnant women with drinking problems
                           has not been studied.

Refer pregnant client      Some women who screened positive for
who drinks during          drinking problems during pregnancy may
pregnancy                  require referral for alcohol counseling
                           which includes setting drinking limits and
                           identification of strategies to avoid
                           behavioural triggers for risk drinking. (55)
                           Counseling every 2 to 4 weeks throughout
                           gestation, as well as access to consultation
                           with social workers and psychiatrist--and
                           for those who failed to return for
                           follow-up, a telephone call or home visit
                           by a local antenatal nurse--was effective
                           in reducing drinking by at least 50% in 55
                           of the 85 women identified as having
                           problem drinking behaviour (n = 29
                           alcoholics, n = 30 heavy drinkers, and
                           n = 26 moderate drinkers). (58) In the
                           group of women who reduced drinking, 40%
                           of infants developed fetal damage compared
                           to 85% in the group of women with no
                           decrease in alcohol consumption during
                           pregnancy. (58) The cost-effectiveness of
                           referrals (i.e., counseling) for pregnant
                           women with drinking problems has not been
                           studied.


Acknowledgements: We thank Nancy Edwards and Nicole Toner for their assistance with revisions. Dr. Semenic was supported by a CHSRF Postdoctoral Fellowship during the conduct of this project.

Received: August 18, 2008

Accepted: March 9, 2009

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Shahirose S. Premji, RN, NP (Neonatal), PhD, [1] Sonia Semenic, RN, PhD [2]

Author Affiliations

[1.] Associate Professor, Faculty of Nursing, University of Calgary, Calgary, AB; Neonatal Nurse Practitioner, Department of Pediatrics (Neonatology), Calgary Health Region, Calgary, AB

[2.] Assistant Professor, School of Nursing, McGill University, Montreal, QC; Nurse Scientist, McGill University Health Centre, Montreal, QC

Correspondence and reprint requests: Dr. Sonia Semenic, School of Nursing, McGill University, 3506 University St., Montreal, QC H3A 2A7, Tel: 514-398-1281, Fax: 514-398-8455, E-mail: sonia.semenic@mcgill.ca
Table 1. Extent to Which Canadian Prenatal Record Forms Integrate
Key Recommendations from Canadian Guidelines for the Diagnosis
of FASD

                                  Provinces and Territories
                                    (revision date)

                                          AB                 BC
                                        (2007)             (2007)
Recommendations

Prenatal Screening
  for Maternal Alcohol Use
  Pre-pregnancy use of ETOH              x (!)               x
  Validated screening tool
    (e.g., T-ACE or TWEAK)                              x ([dagger])
  Screened for one or more
    interrelated risk factors
    which predict alcohol
    consumption during
    pregnancy                              x                 x
Assessment of Alcohol Exposure
  Quantity of ETOH consumed                x                 x
  Type(s) of ETOH consumed
  Pattern of drinking, i.e.,
    binge drinking                         x                 x
  Frequency of ETOH use,
    i.e., daily                            x
  ETOH presently consumed                  x                 x
  ETOH quit date                           x                 x
  Source of information:
    Confirmed vs. speculative
    (e.g., self-report, legal
    and medical records,
    or clinical observation)
Intervention and Referral
  Advise abstinence throughout
    pregnancy
  Offer early, brief
    intervention
  Referral to specialized
    resources

                                  Provinces and Territories
                                    (revision date)

                                          MB                 NB
                                        (2007)               nd
Recommendations

Prenatal Screening
  for Maternal Alcohol Use
  Pre-pregnancy use of ETOH
  Validated screening tool
    (e.g., T-ACE or TWEAK)                x *
  Screened for one or more
    interrelated risk factors
    which predict alcohol
    consumption during
    pregnancy                              x                 x
Assessment of Alcohol Exposure
  Quantity of ETOH consumed                x
  Type(s) of ETOH consumed
  Pattern of drinking, i.e.,
    binge drinking
  Frequency of ETOH use,
    i.e., daily                            x
  ETOH presently consumed                  x                 x
  ETOH quit date                           x
  Source of information:
    Confirmed vs. speculative
    (e.g., self-report, legal
    and medical records,
    or clinical observation)
Intervention and Referral
  Advise abstinence throughout
    pregnancy                              x
  Offer early, brief
    intervention                           x
  Referral to specialized
    resources                              x

                                  Provinces and Territories
                                    (revision date)

                                          NL                NWT
                                        (2004)               nd
Recommendations

Prenatal Screening
  for Maternal Alcohol Use
  Pre-pregnancy use of ETOH                x
  Validated screening tool
    (e.g., T-ACE or TWEAK)        x ([double dagger])       x *
  Screened for one or more
    interrelated risk factors
    which predict alcohol
    consumption during
    pregnancy                              x                 x
Assessment of Alcohol Exposure
  Quantity of ETOH consumed
  Type(s) of ETOH consumed
  Pattern of drinking, i.e.,
    binge drinking
  Frequency of ETOH use,
    i.e., daily
  ETOH presently consumed                  x                 x
  ETOH quit date
  Source of information:
    Confirmed vs. speculative
    (e.g., self-report, legal
    and medical records,
    or clinical observation)
Intervention and Referral
  Advise abstinence throughout
    pregnancy
  Offer early, brief
    intervention                           x
  Referral to specialized
    resources                              x

                                  Provinces and Territories
                                    (revision date)

                                          NS                 ON
                                        (2007)             (2005)
Recommendations

Prenatal Screening
  for Maternal Alcohol Use
  Pre-pregnancy use of ETOH
  Validated screening tool
    (e.g., T-ACE or TWEAK)
  Screened for one or more
    interrelated risk factors
    which predict alcohol
    consumption during
    pregnancy                              x                 x
Assessment of Alcohol Exposure
  Quantity of ETOH consumed                                x (!)
  Type(s) of ETOH consumed
  Pattern of drinking, i.e.,
    binge drinking
  Frequency of ETOH use,
    i.e., daily
  ETOH presently consumed                  x                 x
  ETOH quit date
  Source of information:
    Confirmed vs. speculative
    (e.g., self-report, legal
    and medical records,
    or clinical observation)
Intervention and Referral
  Advise abstinence throughout
    pregnancy
  Offer early, brief
    intervention
  Referral to specialized
    resources

                                  Provinces and Territories
                                    (revision date)

                                          PEI                QC
                                        (2005)             (2004)
Recommendations

Prenatal Screening
  for Maternal Alcohol Use
  Pre-pregnancy use of ETOH
  Validated screening tool
    (e.g., T-ACE or TWEAK)                x *
  Screened for one or more
    interrelated risk factors
    which predict alcohol
    consumption during
    pregnancy                              x                 x
Assessment of Alcohol Exposure
  Quantity of ETOH consumed                x
  Type(s) of ETOH consumed
  Pattern of drinking, i.e.,
    binge drinking
  Frequency of ETOH use,
    i.e., daily                            x
  ETOH presently consumed                  x                 x
  ETOH quit date
  Source of information:
    Confirmed vs. speculative
    (e.g., self-report, legal
    and medical records,
    or clinical observation)
Intervention and Referral
  Advise abstinence throughout
    pregnancy                              x
  Offer early, brief
    intervention                           x
  Referral to specialized
    resources                              x

                                  Provinces and Territories
                                    (revision date)

                                          SK                 NU
                                        (2004)             (2007)
Recommendations

Prenatal Screening
  for Maternal Alcohol Use
  Pre-pregnancy use of ETOH
  Validated screening tool
    (e.g., T-ACE or TWEAK)
  Screened for one or more
    interrelated risk factors
    which predict alcohol
    consumption during
    pregnancy                              x                 x
Assessment of Alcohol Exposure
  Quantity of ETOH consumed                x
  Type(s) of ETOH consumed
  Pattern of drinking, i.e.,
    binge drinking                                           x
  Frequency of ETOH use,
    i.e., daily
  ETOH presently consumed                  x                 x
  ETOH quit date
  Source of information:
    Confirmed vs. speculative
    (e.g., self-report, legal
    and medical records,
    or clinical observation)
Intervention and Referral
  Advise abstinence throughout
    pregnancy
  Offer early, brief
    intervention
  Referral to specialized
    resources

Note: FASD = Fetal Alcohol Spectrum Disorder; nd = Not Dated; AB =
Alberta; BC = British Columbia; MB = Manitoba; NB = New Brunswick;
NL = Newfoundland and Labrador; NWT = Northwest Territories; NS =
Nova Scotia; ON = Ontario; PEI = Prince Edward Island; QC = Quebec;
SK = Saskatchewan; NU = Nunavut; ETOH = Alcohol; T-ACE = Tolerance,
Annoyed, Cut-down, Eye-opener; TWEAK = Tolerance, Worry, Eye-opener,
Amnesia, Cut-down

(!) Included in an accompanying questionnaire

* T-ACE

([dagger]) TWEAK

([double dagger]) Modified version of T-ACE

Table 2. Rate of Maternal Alcohol Consumption during Pregnancy, * by
Province/Region, Canada, 2000-2001, 2003 and 2005

Province/Region              Mothers * Who Reported Drinking
                             Any Alcohol during Pregnancy

                               2000-2001

                             Rate (%)      95% CI

Newfoundland and Labrador    4.9 (#)      (1.5-8.2)
Prince Edward Island        ([dagger])
Nova Scotia                    6.6        (3.7-9.4)
New Brunswick                  6.6        (3.4-9.9)
Quebec                         22.4      (19.0-25.7)
Ontario                        10.2      (8.7-11.7)
Manitoba                       5.0        (2.3-7.6)
Saskatchewan                   8.3       (5.0-11.6)
Alberta                        7.9       (5.5-10.5)
British Columbia               10.3      (8.0-12.7)
Territories **                 7.6       (5.0-10.3)
CANADA                         12.2      (11.1-13.2)

Province/Region              Mothers * Who Reported Drinking
                             Any Alcohol during Pregnancy

                               2003

                             Rate (%)      95% CI

Newfoundland and Labrador   ([dagger])
Prince Edward Island        ([dagger])
Nova Scotia                     9        (5.2-13.3)
New Brunswick                   8        (3.8-12.0)
Quebec                          27       (23.0-30.8)
Ontario                        10.1      (8.5-11.7)
Manitoba                       6.1        (3.1-9.0)
Saskatchewan                   6.6        (4.0-9.2)
Alberta                        5.5        (3.3-7.7)
British Columbia               9.5       (6.9-12.1)
Territories **                 8.9       (3.4-14.5)
CANADA                         12.4      (11.3-13.6)

Province/Region              Mothers * Who Reported Drinking
                             Any Alcohol during Pregnancy

                               2005

                             Rate (%)      95% CI

Newfoundland and Labrador    4.1 (#)      (0.9-7.3)
Prince Edward Island        ([dagger])
Nova Scotia                    8.6       (4.4-12.9)
New Brunswick                5.4 (#)      (1.7-9.1)
Quebec                         17.7      (15.1-20.2)
Ontario                        9.7       (8.1-11.4)
Manitoba                       5.8        (3.1-8.4)
Saskatchewan                   7.2       (4.0-10.4)
Alberta                        5.9        (3.7-8.1)
British Columbia               8.9       (6.3-11.4)
Territories **                 6.0        (2.8-9.2)
CANADA                         10.5      (9.5-11.4)

Source: Statistics Canada. Canadian Community Health Survey,
2000-2001, 2003, 2005.

* Women who gave birth in the five years preceding the survey;
denominators exclude responses of "do not know" and "not stated,"
and refusal to answer.

(#) High level of sampling variability.

([dagger]) Estimates not shown because sample size was less than 10.

CI Confidence interval

Reprinted from Canadian Perinatal Health Report, 2008 Edition,
Public Health Agency of Canada, p. 240, copyright 2008, with
permission from PHAC.
COPYRIGHT 2009 Canadian Public Health Association
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2009 Gale, Cengage Learning. All rights reserved.

Article Details
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Title Annotation:QUALITATIVE RESEARCH; fetal alcohol spectrum disorder
Author:Premji, Shahirose S.; Semenic, Sonia
Publication:Canadian Journal of Public Health
Article Type:Report
Geographic Code:1CANA
Date:Jul 1, 2009
Words:7106
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