Alcohol abstinence in pregnancy

 

Sammi: Good evening everybody and welcome to this evening’s Alcohol Abstinence in Pregnancy: FASD facts, screening, brief advice at point of care, and referral pathways webinar. My name is Samantha and I am your host this evening. Before we jump in I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work and we pay our respects to Elders past and present.

A bit of housekeeping that I am going to take you through quickly just so you know how to interact with us and your control panel this evening. So you should all be able to see a control panel like the image that is currently on your screen. If you cannot have a look in the top right hand corner of your screen for a small red arrow. If you click on that arrow, it will pop out the rest of your control panel. Your control panel provides you with tools to select if you are listening in to us via your microphone and speakers tonight or if you have joined us over the telephone. It also provides you with a place to ask questions. Okay. Everybody has been placed on listen only mode tonight. This is to make sure that learning is not disrupted by any background noise. As I said though, you do have a chat box and we do encourage you to send us any questions or thoughts or comments as we make our way through the session. We do do our best to get back to everybody online, but in the interests of time it is not always possible. If we do not get to your question, do not stress, at the end of the webinar we will post an email address out in the chat box where you can send through any unanswered questions.

Okay, I would like to introduce our presenters for this evening. We are joined by Professor Elizabeth Elliott, Dr Linda Mann and Justine Salisbury. Elizabeth is a distinguished Professor in Paediatrics and Child Health in the Sydney University School of Medicine and Health, a Consultant Paediatrician at Sydney Children’s Hospitals Network. Elizabeth has been involved in clinical services, research, advocacy and policy development regarding foetal alcohol spectrum disorders in children and alcohol use in pregnancy for over 20 years. She chaired the National Foetal Alcohol Spectrum Disorders Technical Network convened by the Australian Government Department of Health. Head of the New South Wales FASD Assessment Clinic and is the Co-Director of FASD Research Australia and NHMRC’s Centre for Research Excellence. So, welcome Elizabeth.

And we are also joined by Dr Linda Mann. Linda is a Fellow of the RACGP and member of the RACGP Antenatal and Postnatal Care Network. Linda has both local and international medical experience, especially in genetics and women’s health. She is a GP representative on various national and local government committees, and is an experienced medial educator.

And finally we are joined by Justine. Justine is a Senior Project Officer of the New South Wales Get Healthy in Pregnancy Service, as well as a midwife and registered nurse. She has been working in both education and clinical services management for over 25 years, in both public and private sectors, with 18 years’ experience working in the fitness industry with a major focus on women’s health and pregnancy exercise. Justine is a keen advocate for women’s health in pregnancy. So, welcome Elizabeth, Linda and Justine and thank you for joining us all this evening.

Linda: So by the end of this online QI and CPD activity, you should be able to understand the rates of alcohol use in pregnancy in Australia and the risks of pre-natal alcohol exposure for your patients and their children. Identify opportunities for discussion with your patients about the harms of alcohol use in pregnancy, and be familiar with the advice contained in the National Guidelines. And we are referring to a 2009 document. Use the Audit-C tool to screen patients and identify their level of risk and the need for support, brief intervention of referral to specialised services. And, list the benefits of the free Get Healthy in Pregnancy Alcohol Abstinence program.

Elizabeth: In your general practices, you are likely to see women with alcohol use disorders. You will see women who drink alcohol during their pregnancy. You will see parents of children with foetal alcohol spectrum disorders and other effects of pre-natal alcohol exposure. And you will see children and adults with foetal alcohol disorder, many undiagnosed. GPs are ideally placed to ask and advise women about alcohol use in pregnancy, its potential harms and to refer when required. GPs may also provide contraceptive advice to women who chose to drink alcohol.

In Australia, we have a drinking culture with high rates of binge drinking in teenagers. High rates of unplanned pregnancy, probably 50% and high rates of alcohol use in pregnancy. So, are women really still drinking in pregnancy? Well, WHO data shows that internationally about 10% of women across the world drink in pregnancy. But remember many groups of women do not drink at all. And this is very variable with high rates in Eastern Europe. But the National Household Survey in Australia, the last being in 2016, shows that 50% of women drink in pregnancy before they are aware that they are pregnant. And 25% continue to drink throughout the pregnancy. This is higher than we have had in the previous survey of 2010, and interestingly, it is the older women, those of higher socioeconomic status and higher educational levels who are the ones that continue to drink.

On New South Wales, we have done some work in using data linkage in over four hundred thousand pregnancies and we found to our surprise that one in one thousand of those women had one or more alcohol related admissions during their pregnancy and in one fifth of these women, the alcohol problem was first identified on the day of delivery.

We also know that there is high risk drinking in some select communities, so for example some remote Aboriginal communities. And in some work that we have done in remote Western Australia, we found that 55% of women of primary school age children were drinking at high risk levels during their pregnancy. But we have got to remember that this is not a problem restricted to Aboriginal communities. And we have two pregnancy cohorts that we are following in Victoria and in New South Wales and WA, with about fifteen hundred women in each. And in both of those studies, 60% of women told us they drank before they were aware that they were pregnant. And those who drank before they were aware, were often drinking at risky levels. And often it was related to a special occasion. Their brother’s wedding, their sister’s 21^st. And in some preliminary data that we have got from the Hunter New England, we are realising that the rate is very similar in that population as well.

So, why do women drink during pregnancy? Well, Liz Peadon, a developmental paediatrician recently did really a national representative survey of women of childbearing age and she found that a third of those women were unaware of the harms of alcohol use in pregnancy. Furthermore, what she found was that 20% had a tolerant attitude to alcohol use. So she gave them a scenario of a very pregnant women very drunk in the pub. And 20% of them said, well that is their business, it is a free world, we are not going to tell them to stop. And what was interesting is that it was these women who had the tolerant attitude to alcohol use in pregnancy who themselves had drunk in a prior pregnancy and proposed to drink in a future pregnancy. And this tolerance was not associated with knowledge of harms of alcohol. So, that poses a real problem for us as health professionals. We can educate people but unless we can change their attitudes, we will not change their behaviour. And in this particular study, drinking was also associated with previous alcohol use in pregnancy, a partner who drinks, smoking and a woman who drank at risky or harmful levels before pregnancy.

So what about indigenous women? Well, we have done some focus group work in Western Australia and indigenous women are pretty well informed of the harms of alcohol but they tell us that we must remember that they drink in response to stress. Now this might be stress of their current disadvantage. So the communities I work in are very remote. There is little employment. There is no transport. There is a lot of drug and alcohol use. A lot of overcrowding. But also, they are women and families who have been in the previous generation moved off their traditional lands, prevented from speaking their traditional languages, taken into Mission Schools and many of them have been involved in the stolen generation. So these women are really drinking because all of the community is drinking and they do not intend to harm their baby, they just continue to drink at the same levels during their pregnancy.

Linda: Elizabeth do you think that that historic trauma stress is relevant to the Aboriginal people that we see in the cities?

Elizabeth: Yes. I think we really underestimate, Linda, the effect of historic trauma, and I did not really understand it until I have spent now over 10 years working in these very remote communities. And it really is just trauma that has never been resolved from one generation to the next. And for example, we are running a parenting program in Fitzroy Crossing at the moment, and it has raised a whole lot of issues, because some of the women who are being trained to help parents deal with child behaviours, have themselves never had any parenting because they have been separated from their parents. So they do not know how to parent, they have never, they have not got a role model. So that is just one example of how the trauma can pass from generation to generation. And I guess the other thing is now that we know about epigenetics and the impact of environmental exposures on switching genes on and off which may have an impact on future generations, then I think that there is likely to be a lot of effect of all these issues, trauma, alcohol, cigarettes et cetera on the next generation. Nutrition. Through epigenetic mechanisms.

Linda: Thanks.

Elizabeth: So, what are the risks of alcohol? Well, I think we all know. We have learnt in medical school that alcohol is a teratogen. That is, it disrupts the development of the body structures in the embryo. And it is also neurotoxic. We know that from our adult patients. So, any child exposed prenatally to alcohol is potentially at risk of harm. And I guess this is one of the few causes of brain injury that can be prevented. So we all know that when we drink we develop a particular blood alcohol is passed to the foetus via the placenta. And the harm to the foetus or the potential for harm obviously depends on the dose of alcohol, the amount of alcohol, the frequency and the timing in pregnancy. But I am often asked well you know, how much can I drink? And I think that the answer should be for all of us that we cannot predict the risk in an individual pregnancy and that is because there are a whole lot of maternal and foetal factors that we cannot factor in. So for example, there are three or four hundred genes for alcohol metabolism. My genes might be different from Justine’s. My foetus’s genes might be different from yours. I am older, I can see that. I have got a different body composition. I may have different pre-existing illnesses. So really it is very difficult to predict risk and therefore the safest option is for us to be, you know taking a preventative approach, advising women that the safest option is not to use alcohol.

Next slide please, Sammi. I put this slide up just really to remind us how much is going on in that first trimester of pregnancy and this unfortunately is often when women do not realise they are pregnant and this is where GPs have such an important role, because you know your patients, you know the patients that are drinking at risky levels and the patients that are wanting to have a baby. So you can see in that first trimester, limbs, eye, heart, ear, pallet, central nervous system development. But the important point on this slide is that the brain continues to develop through the second and third trimester and I think gains significantly, maybe 30% in weight in that third trimester. So we have got to get the message across that it is not safe to start drinking after the first trimester. We have actually got to avoid alcohol through the second and third trimesters.

So alcohol can harm the mother and pregnancy. We know that alcohol harms our health, our mental health, can disrupt our relationships, can be related to domestic violence and injury. But there are also adverse effects on the pregnancy and we have now got some good data to suggest that women who drink a moderate amount in pregnancy, book late, babies have low APGAR scores and may require special care or NICU. We know that women who drink are more likely to have spontaneous abortions and babies who are small for gestational age, prematurity. We know that still birth is associated with alcohol use in pregnancy.

Next slide. We also know through following big, large numbers, tens of thousands of children through linked data sets, particularly in WA, that if a woman drinks alcohol in pregnancy, her child is more likely to have birth defects, cerebral palsy, language delay, intellectual disability, that SIDS is more likely and various mental health problems. And indeed, in Western Australia, we reckon that a third, sorry 1.3% of preventable disability in non-Aboriginal or Torres Strait Islanders, and 16% of disability in Aboriginal and Torres Strait Islanders could be prevented if we could prevent women from drinking at these levels in pregnancy. There is also some data recently from the WA Birth Defects Register, which showed that the most common cause of microcephaly, that is a head circumference less than the third centile, was foetal alcohol spectrum disorder over a number of years.

We can also follow these kids through data linkage as they go through school, through the health system et cetera, and we know that those who are exposed to alcohol are more likely to later have contact with child protection and justice systems and to live in out of home care. And furthermore, that they have poor school attendance and academic outcomes. And this is not children with foetal alcohol spectrum disorder. These are well established associations of alcohol in pregnancy. So really the most severe ultimate effect is foetal alcohol spectrum disorder. And this is the result of an acquired brain injury due to prenatal alcohol exposure, and we have just got to remember that it can have life-long consequences. So we know that these kids grow up to require support. They often, very few can live and work independently. They have increased rates of mental health problems and substance use. And we also now know that they have increased rates of renal and respiratory and other diseases. And again, we think that might be the epigenetic effects of alcohol exposure in utero. Indeed in a big Canadian study, the mean age of death of people with foetal alcohol spectrum disorder was 34 years.

So to help doctors and nurses and Allied Health professionals sort of think about this diagnosis and know how we approach it, we produced this Australian Guide to the Diagnosis of Foetal Alcohol Spectrum Disorder. This is available on line. So even if you do not think that you are going to be diagnosing this disorder, it is really helpful we hope to just let you know what is required. And of course there is quite a lot that a GP can do before there is a referral to a paediatrician. So the diagnostic criteria are, prenatal alcohol exposure, severe neurodevelopmental impairment in at least three domains of function, and I will show you what those are in a minute. And unlike in the old days when we only talked about foetal alcohol syndrome, these children may or may not have facial features and birth defects. So in other words, if there is alcohol exposure at a critical time in the first trimester then there may be birth defects and there may be facial features. However, we know now that probably, it is about a ratio of one in ten, one child will have the three facial features for every nine that will not have. Of course it is important to exclude differential diagnoses. We do not want to be diagnosing every child with foetal alcohol spectrum disorder. We have got to look at their genetics. We have got to look at other causes of severe neurodevelopmental impairment. And this is really just to give you an idea of the domains that we assess. When I say severe impairment in at least three domains, we really want to be using a standardised test such as a WISC for IQ and documenting that this child is scoring in the relevant domains below, two standard deviations below the mean.

Now again I have put this up. I have just emphasised that probably only one in ten children with foetal alcohol spectrum disorder will have these typical facial features, but just to remind you, if you look at the top two panels on your right, panels four and five, you will see those kids with a very thin lip and the indistinct philtrum. So that is the eye opening which reflects the size of the eye which in turn is determined by the brain and can be impaired by alcohol. And we will measure the eye and plot that against normative values and again we want to see it to have a small palpable fissure, the measurement to be two standard deviations below the mean. And to be significant the lip and philtrum should run four or five. Now if you have these three features which occur in a window really of embryology, then there is a high sensitivity and specificity for this diagnosis in the presence of alcohol exposure. And if you look at that panel down the bottom, I think you will agree that these features hold fast whether you have got a Hispanic, Caucasian or Afro-Caribbean child. And we have done a lot of work in Aboriginal children and we feel that these features hold fast and we use for Aboriginal children the Afro-Caribbean lip philtrum guide which was the one on the right.

So, really in summary we now make a diagnosis of foetal alcohol spectrum disorder based on severe neurodevelopmental impairment, proven documented alcohol exposure during pregnancy and we then categorise it as to whether or not there are three facial features. And of course some of these children may have birth defects. They may have structural brain abnormalities such as microcephaly or an abnormal corpus callosum. They may have growth failure and many of them will have life-long problems.

I just put this up to let you know that if you have children that you require an assessment on, we now have some funding for a very part-time foetal alcohol spectrum disorder assessment clinic at The Children’s Hospital and Westmead where we provide an assessment and a multidisciplinary service and we take referrals from general practitioners. Most of the kids we see there are children in foster or out of home care.

Linda: Elizabeth, you said before that there were things that the GP could do. Clearly if a GP identifies a child that they are worried about they are going to send them in the first instance to a paediatrician because that is the easiest resource we have got. What else can we do?

Elizabeth: Yes, well look you can document the alcohol exposure and you are often in a very good position to do that because you know the patient, you may have their pregnancy notes available to you. And so you can document that. And you can confirm that with your patient. And most women are you know, really willing to report on their alcohol, their drinking behaviour. The second thing you can do, is look to see whether that child has, what are the concerns of the mother, what are the concerns of the school? Has that child been assessed by an Allied Health Professional, a psychologist et cetera? And if so, we are quite happy to take those assessments provided that they are recent. So a recent IQ assessment or a recent physio assessment, or a recent language assessment. And, I guess the next thing you can do is to refer to a paediatrician and they can check that the child has not got any stigmata of any other neurological disorders. They can confirm the facial features, they can use the facial photography software that we use if they have got that available. And then, they can refer to us or you can refer direct to us. But I guess what we are trying to do at the moment is just increase awareness in the health professional population across the board, and you know we can perhaps discuss later about why would we make a diagnosis? Why would we want to make a diagnosis? Is it worthwhile? But I think for a GP, the key thing is, thinking about alcohol. Asking about it. If you are able to document alcohol use in pregnancy, then think how this might be affecting the child. What is happening at school, what is happening at home? Have they got behavioural problems? Have they got learning problems? Have they got any significant birth defects or other medical illnesses?

Linda: Thank you.

Elizabeth: I hope this resource will be useful to you. We had some Government funding to develop this resource called the FASD Hub. It is really intended for health professionals. It provides a lot of information, a lot of Australian research. It provides some resources about where to refer children in individual states. And it also provides some nice little videos and some information for parents and care givers.

So, handing on to Linda.

Linda: You may be familiar with a process that has been around in the general practice environment for a bit, which is called the five As. I guess many of the audience will be familiar with this. I am going to talk about it again because it is a really useful resource. It really helps direct a conversation that we need to have and it has been developed in a way that is a very general. Very, very general practice appropriate. So, the first thing you want to do is ask people, well women in this case, about their alcohol use. We have already mentioned the fact that pregnancies are often unplanned and as a result many people will have been exposed to alcohol early in the pregnancy. One of the risks obviously is that where alcohol is an issue, is where that diagnosis of pregnancy is in fact later.

It is helpful when thinking about this, to also have the conversation about alcohol at around about the same time as you are talking about contraception. One of the reasons is, is because women are a bit of a captive audience from a contraceptive point of view for us in general practice. But also because it allows us to engage in protective behaviour for people who are drinking and allow people to have a positive thought about limiting their contraception if they are getting to an age where they want to have babies, and therefore tie that to changes in their alcohol behaviour. In that scenario, the following conversations about looking at where they are and how things are going to follow on, is very helpful.

If you have a look at this table that is here, you can see that we can actually make some assessment of the risk in terms of the potential pregnancy of a person according to their contraceptive use and their alcohol use. If we actually ask everybody about this, then we are not targeting folk. It is appropriate to be able to say to women, I have this conversation with everybody, it is a thing we talk about with everyone that comes here. And it takes away the stigma.

I just want to point out to remind you that we do have national guidelines developed by the NHMRC and they quite clearly state for women who are pregnant or planning a pregnancy, not drinking is the safest option. They do go to explain, the more you drink the more likely you are to do harm to your unborn child, and they do also explain in a little bit of detail, that it is very difficult to predict the risk in the individual. Now these are really clear guidelines, but the 2001 guidelines were quite messy, and they said you know, if you try not to drink in pregnancy but if you have to drink, do not drink more than two drinks a day or seven a week and do not get drunk. So I think these are a much clearer message, and we have good information from surveys we have done in women that they want to be given a very clear message. They want to be told and in fact in about 90% of cases, not to drink alcohol during pregnancy. So it is interesting because doctors are unwilling to give that advice. Women want that advice.

And in fact one of the things that follows on from that, is actually assessing what people are doing. Now, I am sure you have had the same experience that I have had, where you ask a person about how much they drink and they say, look I am really good, I know I am only supposed to have this many drinks in a week so I have them all on a Saturday and I am really good for six days a week. And you say back to that person, oh, you are a binge drinker. And they go, sorry? I am a what? People do have some knowledge but they will filter it according to their own desire and interpretation. So using this particular tool, the Modified Audit C tool, is actually quite helpful for laying it out for people about where their risk really, truly is. So what you want to ask is three simple questions. How often do you have a drink containing alcohol? And you will notice it is a bit more specific than the little spot in our software that does not allow you to make this much detail. How many standard drinks of alcohol do you drink on a typical day when you are drinking? And again, if you just use the alcohol input on Best Practice or Medical Director or whatever you are using, you will not get this level of detail, so you need to actually put this information into the body of your notes. And how often do you have five or more drinks on one occasion? My experience is that people are surprised when I reflect back to them what the significance of that last one is. So we found it very useful to use a standard drinks guide, because the Audit C, when we ask people how many drinks they have, we really want to know how many standard drinks they have and a lot of people do not have an understanding that the average glass of wine that we pour for ourselves on a Friday night might contain three or even four units of alcohol, so it is really important that patients can point to a chart like this and say exactly what they usually drink, how many of those, and then you can calculate how many standard drinks that is and insert that into the Audit C to determine risk.

Elizabeth: I think charts like this are easily available on google images.

Linda: Yes, and they are also available in the guide to the diagnosis of FASD that I mentioned. And we ask the same questions in pregnancy. So we are interested in what they are drinking during their pregnancy and using the Audit C to score. But remember to ask that question, what about before you realised you were pregnant? Were there any special occasions?

So we have asked, we have assessed. So the next thing that people are looking for us to do, is to advise. And they need that as Elizabeth has said, these women want to know what the right thing is. They would actually like boundary, definite, not namby-pamby advice. And the easy thing to say is, the safest option during pregnancy is to avoid all alcohol. Now, some women will interpret that as oh my God, I put my child at risk. Assess that. Go through this process and see whether that is true. If it is true, then that is something that can be noted as a problem on the yellow card for future assessment. A lot of women that you will speak to that have been exposed to alcohol before they knew they were pregnant, were drinking at such a level that you can provide reassurance because now they are not going to drink again in pregnancy. That is a good outcome.

We know that there is no safe level of alcohol consumption, so we cannot absolutely reassure people, but I think it is useful for the risk that people who have been exposed to alcohol to be recognised. Not as something to give them stress through the pregnancy, but as something to watch. Of course, people who in fact tell you that they have not been drinking before pregnancy or since they recognised they were pregnant, have not drunk, should be absolutely patted on the back for doing what they are doing.

There are some resources that we can use that help in this. So one of those resources is the Women Want to Know resource, and they really arose out of that study I mentioned by Dr Liz Peadon, where we found that doctors were not asking and advising but women were wanting to be asked, advised and then indeed given a very clear message. These are freely available on the Australian Government Department of Health, I think if you just google Women Want to Know, you will find those resources. And they do contain a couple of little videos of a GP and a midwife interviewing a mother and you know, you can decide whether you would do it that way or some other way, but they are good points for discussion, particularly for your trainees to have a look at. And they do provide resources that you can give out to your patients.

The other one that has recently been produced is by New South Wales Health, and this is particularly relevant to people who are working in populations where they are seeing Aboriginal and Torres Strait Islanders and there is a series of resources really. So there is information for health professionals and there are a series of five little videos. They are very engaging. They are short, four or five minutes. They are quite funny and they are intended for women, for men, for youth and for health professionals, and I think you have got the website there on your slide.

So we have asked, we have assessed, we have advised. So now what we can do is to assist women to stop using alcohol and this is doing the thing that we do all the time, the fancy name is brief intervention. The more nuanced thing that we do is motivational interviewing. We are familiar with doing this in cigarette smoking, we are familiar with doing this in domestic violence assessment and it is bread and butter for conversations about alcohol use.

Elizabeth: Just to butt in there, Linda. I mean there is really good evidence from randomised trials that this sort of intervention is effective, so yes, fully support that intervention.

Linda: So when there is information that is discovered in your previous conversations about people’s use of alcohol, we have an amazing authority to deliver information away that guides people forward. People listen to us if we talk about the benefits of abstinence. We can hear the situation that a woman is in because often we may know it already and they know from the relationship that we have with them, that this is not a blame scenario, this is a support scenario. We can actually look at their strategies and support them and we have access to resources that we can provide for them and refer onwards as we are going to talk about in a second. These kinds of interventions do not take long, five to 10 minutes. It does not matter if you have done it before, you can do it again. You know that there is an expectation that women will be asked about things like cigarettes and alcohol use and in my experience, are basically pretty honest about how they respond.

So having identified that there are things that can be done, then the next thing you can do is to arrange some help. So looking at those Audit C screen results, they come out in three different levels. People who are not drinking alcohol so who are in pregnancy not at risk. People who are drinking, either were drinking or drinking at a low level who are low to medium risk, who may not yet be pregnant. And people who are screened as being at a high risk. For the people who are at no risk, there is a lot of support to be done. One thing I would recommend however, is that you do not take one assessment as the end of that woman’s life. You know we do a wonderful assessment when we first see the patient, new patient and you know, tick a box social history, pretty good. And then we forget about it. And this is where I am suggesting that every time that you renew a person’s for example contraception, or any other routine aspect, you ask again about their alcohol use, because you know what, it might change with time and it certainly might change with a new partner.

For people who are assessed as low to medium risk, there are resources that are available. One of the most impressive of which is the Get Healthy in Pregnancy Alcohol Abstinence Program that we are going to hear about in a second. And, there may be drug and alcohol counselling appropriate for them which we can access through the resources that we already have as GPs.

And for people who are at high risk, there is a lot of benefit in having a conversation about referral to the specialist alcohol services that are available in your area. And the Get Healthy Service alcohol reduction program which is designed for this process. I will say again, that use of the appropriate contraception for people who are not pregnant and who are at high risk, is highly valued. And think about long-acting reversible methods of contraception, because you know what, if you are a binge drinker or any other kind of drinker, it can be awfully hard to remember to take those pills every day. And then you end up pregnant, and here we are.

Justine: Okay. So, the Get Healthy in Pregnancy Service started in 2016 and in 2017, we actually started the Get Healthy in Pregnancy Alcohol Abstinence Program. We really saw a need to actually have this healthy behavioural change program within our coaching call program. It is completely free of charge, it is available to all New South Wales residents 18 years and over for the Abstinence program. Obviously if you have got a lady who is under the age of 18, then you need to do more local support for her. But yes, it is based on the NHMRC guidelines. We use motivational interviewing and positive psychology. We address nutrition, weight and physical activity alongside of that. But we do do four coaching calls if we do identify through the Audit C tool that these women are at risk. We do actually do four brief intervention coaching calls.

We then feed back to the GPs, so you guys will actually get feedback. We give you feedback on enrolment, mid-way, graduation and if they withdraw from the program. So if you refer into the service and we will show you how to do refer in a moment, you will actually get good support throughout to know that your client is actually following through with the program. We also have GP support materials and there is actually a higher retention rate if women are referred by a GP rather than just handed a pamphlet, and that is where it comes down to how assertive we are. If we really want those women to go through with that, then that is super important that we make sure that we think this is really important for them.

So we have two levels of service in the Get Healthy in Pregnancy Service. They can actually get an information only booklet, so where they can actually have a one-off advice session with a health coach, and they can continue with the coaching if they like, but they can be send out an information booklet and that gives them just a really brief snapshot. The bests really for women who are identified at being at risk of drinking alcohol, is really the coaching call service, so you actually get 10 free telephone coaching sessions with an exercise physiologist or a dietician, and that can go over a six month period of time. It does not have to all happen during the pregnancy, it can actually extend beyond their pregnancy and post-pregnancy and between pregnancies is actually a really good time to get on top of these healthy behaviours. And if they are planning pregnancy, the Get Healthy Service is there to help them out as well to ensure that they are in the best of health prior to them having their baby or even trying for their baby.

If the woman is identified as Aboriginal in the referral, it is super important to actually make that obvious to us, because we then use our Aboriginal liaison officer. She will actually guide those Aboriginal participants through the program and they really love that extra added support.

Linda: Can I just ask, what about a person who is having an Aboriginal baby?

Justine: If they identify as having an Aboriginal baby, they can still use the Aboriginal liaison.

Linda: Thanks.

Justine: Okay. And she is a great resource, and usually they have a good old yarn for quite a long time and they tend to find lots of other issues that really they do not want to tell their local midwife. So we do find that when we do that Audit C tool, that first episode of coaching that we have with them. We always do it again regardless of whether they have just done it with someone else, because you just never know. You never know if someone may be, you know, knew somebody and they see them at Coles in their town. We want to make sure that if they are talking to a random person on the telephone it is a little bit anonymous, and they do tend to share a little bit of information with us, which is really super.

If they are actually found to be drinking alcohol at risky levels and that was not actually passed on to us through one of our general referrals, then we actually will get back to you and feed that information back so it does get escalated if we see that there is an issue. And we do refer on to ADIS, so that is the Alcohol Drug Information Service, and they actually do a bit of coaching with them. Obviously if it is immediate risk, again back to you guys as the referrer is where we will head.

So we do have two alcohol coaching programs and we talked about non-pregnant women prior to them conceiving really needing to think about their alcohol consumption. So if you have a woman who is planning a pregnancy or you feel is at child-bearing age and would benefit from having some help reducing her alcohol intake, we do have a Get Healthy Alcohol Reduction program and again, we use the Audit C, not the modified Audit C and we actually will go through that whole thing, and again we will go on to appropriate referrals if they are at risky levels or sometimes if they are very high up in the scoring we do refer them back to you guys or tertiary services. But yes, for pregnant women it is the abstinence program. So we really want them if they are scoring a zero, they can still enrol in the standard Get Healthy in Pregnancy program. Again, we will keep reviewing that. We know now that in antenatal care services, and on eMaternity, so that is the platform that midwives use in the public health system in most districts, they will do the Audit C tool both on admission or booking into the hospital. They will also do it at 28 weeks. Then if they get referred to us, again we will do it again. There is just, you can never do the Audit C, modified Audit C too many times I think. You just need to make sure because there is such a high risk of harm to that bub.

So, if they score one to two, they can enrol into the standard pregnancy program and have an alcohol brief intervention. During this brief intervention, we will have four sessions talking about alcohol reduction. And again, it is motivational interviewing. So we are letting the women really guide their progress through the program and giving them good advice, giving them positive reinforcement if they are doing well, and of course letting them get back on track and re-orientating them to their goals if they are falling off track. And obviously a score of three or more, entry into the Alcohol Abstinence in Pregnancy, but also making sure that the GP and Alcohol Services are aware of their risky behaviours.

Sorry, Linda?

Linda: I was going to ask about the people who score you know, between one and three, so who are drinking something, I just want to get this right, is there an automatic relationship with the delivering hospital? Or are you sort of a separate stand-alone process that relates directly to the women?

Justine: Okay. So it depends on where they have been referred from. In a lot of cases, the women that have been referred from a GP will have that referrer relationship, because you might be doing shared care. So, that shared care connection, you would be as the primary referrer, the person that we report back to. If the woman actually consents to us sending information to the hospital as well, we can actually send to both if she has identified that there are two actual managers of her pregnancy. So we can do that.

Linda: But also, midwives can also refer to you?

Justine: Absolutely.

Linda: Because I have just come back from Taree. We are running a project in the Hunter New England region. We have actually embedded the three questions of the Audit C into the electronic maternity records, educated health professionals and encourage them to ask the questions, but then importantly provided the what they do depending on the risk level. And certainly they are referring to the Get Healthy in Pregnancy program as well.

Justine: And that is the most important thing, is when you do actually ask the question that you have somewhere to send them. And that is I think what they intended in Hunter New England, is to understand, you know to get clinicians to actually first have the conversation and then once they have the conversation to be able to give a little bit of brief advice at that time, because that first bit of brief advice is essential. And then have somewhere, yes, that can actually carry that on, because you may not see that woman again. If you are seeing them at eight weeks, or at you know, sometimes in the first maternity session at 12, then you might not see them for another four to eight weeks. A lot of harm can happen in that time. So making sure that you have referred them to the right service, that will actually get in touch with them as soon as, within three days, is the time if there is a referral put through. And we make sure that we keep trying. If a woman is Aboriginal we will try six times in two weeks to actually get in touch with her. If they are a non-Aboriginal participant we will try four times. If we cannot get in touch we will actually get back to the referrer and say hey, we have not been able to contact your client, we are aware that you wanted them to be referred and we received all your information, can you please chase them up. So, there is good sort of feedback so you can actually get that information back.

Linda: So, sorry to be embarrassing, but does it work? Do you have any evidence sort of, of what we are heavily recommending to general practice at this point?

Justine: At the moment we do not really have a big enough cohort that have gone through the Alcohol program, and I think it is because there is just not enough information out there about the program itself because it has been a little bit overshadowed by our Gestational Weight Gain module. So people are getting referred in through Gestational Weight Gain, they are flicking into the Alcohol a little bit, getting a little bit of advice there and then flicking back to the Gestational Weight Gain. So, we know from good research from other programs that motivational interviewing and brief intervention does work for alcohol, and that is why we are starting to push and get it out there so that people know that we are available for this low level drinking in pregnancy and prevention.

Linda: So, we have got pretty good evidence that coaching as a method, in fact is useful in the health environment, we just have not got the detail for this particular alcohol-related program. Is that about right?

Elizabeth: Not this specific program, but we do have evidence that motivational interviewing does help in alcohol in pregnancy, and so there is data in the literature. Linda, we will have some answers for you soon because in our Hunter New England project, not only are we looking at what health professionals do, we are ringing a random sample of women to tell us whether they were asked about alcohol, what they were advised and whether it changed their behaviour. So that will be very interesting. We have got over five and a half thousand women that we have already rung, and we are continuing to do that, so I think that will be a really important bit of data to say, can we change practice and more importantly, does it have an outcome at the patient end?

Justine: Okay so the benefits of the service. I am looking at some questions here, Sammi, do you want us to answer these questions? It says here Joanna has asked, at what stage would you refer to FACS? If you had concerns about the risk of FASD in regards to a pregnant woman’s alcohol consumption?

Linda: Well my response to that is basically I think the GP should talk to the social worker at the delivering hospital in the first instance before getting FACS involved, because there are larger issues. FACS is a very, very, very large and very blunt instrument that terrifies the pants in my experience off pregnant women and if there are things that can be done in a gentle fashion with FACS at the end of a long corridor rather than first thing, I think that is a much more supportive approach. Do you have a thought about that, Elizabeth?

Elizabeth: Yes. No, look I totally agree. I mean there is no predicting whether that child will be affected or not. If you are really concerned about a family and I have certainly seen children who have been handed into family or out of home care at birth really, if there has been really high level alcohol, but not just that. But if it is deemed by the social worker and the team that that woman will not be able to look after that child after birth either because household is chaotic or there are drugs and alcohol or whatever, but yes we would be very reluctant to be sort of thinking about child protection at that stage during pregnancy, except in extreme cases. And I think this brings up the issues of Aboriginal women. When we are asking about alcohol we have to be sensitive to the fact that many of them have seen their children or their family’s children taken away in one way or another, and they are really worried that if they say they are drinking in pregnancy, some of them, that the child will be taken away. So we are always very clear to make it, we always make it very clear at the outset, that we are not there to shame and blame them. We are not there to take away their children. We are there to really try and assist them to have a healthy pregnancy.

Linda: And I will just give you some statistics from the hospital where I am a VMO. So I happen to be VMO running the Young Parents’ Clinic where we have young parents with all sorts of issues and low level alcohol can be part of that cohort. We use a system called family conferencing which actually starts as early in the pregnancy as we get the woman, and together with FACS, set out goals for the family to achieve. The woman, maybe her partner. Maybe not her partner. Maybe there is other people in the family. But it is a family event with goals to be achieved throughout the pregnancy and using that method, a number of assumptions in that scenario of children taken away from families has gone down year upon year in the last three years, a factor of which we are extremely proud.

Justine: Okay, good. So just remembering too, our service does not take away from the great services that are on the ground. It really is a non-prescriptive service. We need to make sure that if a woman does need one to one care, that is prescriptive, that she keeps on track with those. But we can keep them on track with little goal setting and motivation and just being another friend over the phone that gets that continuous message across.

The referral process is on the next page and women can actually self-refer into the service if they like, but we like a GP referral because as I mentioned before, participants are more likely to stay in the program if they are referred by a trusted health professional, and we found that in our first trial. You need to complete a practitioner referral form and email or fax it to the Get Healthy Service, or you can refer online where it says refer your patients on our website. And Medical Director and Best Practice software do have templates of these referral forms, and hopefully down the track we even might be able to do an electronic referral. We are working hard with that. So, pretty simply you can do it yourself or you can get your practice nurse to do that for you. So as long as they have got some registered nurse background. If they have been referred in by yourself and you have signed the bottom then they do not have to go back to you again for a medical clearance if they have got any comorbidities. So it is good for you to have actually signed that form. And it is quick and easy, it does not take too long. But I mean if you really want this for the benefits for your patients, it is well worth it.

Linda: So one of the good things about the Get Healthy Service from my point of view as a GP is that it a resource for me but the patient comes back. And therefore it is like a step in a long journey, because the journey that we are having is between me and the patient and their family, see what I am saying? The progress information that I get through the times the person attends is helpful to progress the conversations that we are having either before she is pregnant or during her pregnancy. The fact that I know what the goals are that have been discussed at some length, makes those conversations that I am having with the patient so much better because it is actually a great time saver for me. Obviously there is some value in having this information about what the goals were at this time for when things go pear shaped in six months’ time, we can refer back to that information going forward. On the other hand, if things have actually got better and better, it is fantastic to refer back to something where a person was six months before and how much better things are right now. If the patient drops out of the service, then obviously we are given information on that subject which is useful to us if we want to go in a different direction.

Elizabeth: We have just provided a few resources for you if you want to read a bit more about how to support pregnant women who use alcohol or other drugs. These guidelines are developed by the National Drug and Alcohol Research Centre. And on the next page is just a summary of the WHO guidelines which really just reiterate what we have said that we should be asking all women advising the safest option is to stop drinking, providing a brief intervention or if the woman has alcohol dependency, referring for detoxification. And really, encouraging also women to breast feed but to stop drinking alcohol while they are breast feeding and to be aware that if an infant has been exposed in utero, they need to be carefully observed in the neonatal period and flagged really, so that they can be seen subsequently by the paediatric services, particularly if they have developmental problems. But I guess for us as a paediatrician, having that alcohol history there is really helpful when they present to us as they do at seven or eight years of age when they have behavioural problems and difficulty coping at school. If we can go back and get that reliable history that has been taken by the GP or the midwife.

So really just to summarise, alcohol use in pregnancy is common. It can have unpredictable and lifelong consequences, the most end of the spectrum is foetal alcohol spectrum disorder, and you will all see women who use alcohol in pregnancy and you will all see really the product of exposed pregnancies. You really do have many opportunities to intervene to prevent harm, but that does require asking and advising and referring as appropriate. And just remember that women do want health professionals to ask and advise. They have told us that that is where they want to get their information on alcohol use and other aspects of pregnancy. There are guidelines. There are resources. We have identified some of those for you. It is important also to raise this issue of harms of alcohol in your general population of patients. And I think as health professionals also, I feel very strongly that we should be advocating for what we know are evidence based strategies to reduce harm in our general community from alcohol and that is looking at pricing and taxation, looking at opening hours and density of liquor outlets, looking at advertising and promotion. We know that if we address those issues, we will significantly reduce harms from alcohol.

Linda: Justine, can I just ask about … your program?

Justine: Get Healthy Service.

Linda: That is the one. And Communicare which after all is the software that is used in the AMS?

Justine: Yes. I have just seen it and I apologise I did not, I do not know of the Communicare systems yet. We have not done a great deal of work with the AMS to date. We have been into that Aboriginal Maternal and Infant Health Services and the BSF Services, but I will actually look into that. So thank you for that suggestion.

Linda: So some of the other questions that are written here are, about the scenario about the woman who is drinking in a family or in an environment where there are other drinkers, which obviously makes life very difficult. I think that is a very, very difficult problem to face, and I think that is when there is value in getting some help from the drug and alcohol workers who are really experienced in this scenario. Sometimes in families where alcohol is a big deal, there may be already some connection to Allied Health folk, and they can be quite useful. The other resource that I would remind you of, especially for the upper SES population where this will be very well received, is drug and alcohol experienced psychologists who could be accessed using mental health plans. In my experience again, to motivate people to do something that is different to their family, psychologists can be very, very helpful.

One of the other questions here is about women who start drinking in the second or third trimester and what their risk is from the baby’s point of view. Can you answer that one?

Elizabeth: Yes, well look I showed you that chart partly because when I was having my babies, people would say well you are through the first trimester, there is no harm. You can have a drink. But I guess naively, we did not, well you know we realised but we did not think about it, that the brain continues to grow rapidly through those second and third trimesters. So we certainly see children who have had exposure even in the third trimester who have significant dysfunction and that is because the brain is rapidly growing in that second and third trimester. And right towards the end of pregnancy, there is development of neurotransmitters and connections between the hemispheres and the sort of sophisticated pathways developing in the brain. So, really my advice would be that, that is why we are really suggesting that you ask throughout the pregnancy not just at the first visit. And my advice would be that whatever stage of the pregnancy you identify women are drinking, you try to support them to stop drinking.

Linda: But in terms of supporting them to stop drinking, one of the questions has asked about pregnant women who might wish to undergo alcohol withdrawal. My advice to you as an ancient and legally knowledgeable GP, is unless you are really good at this, you get the help of your specialist colleagues. Now, whether a woman is to be admitted or whether she can actually have an alcohol detoxification in the community would be up to the people who are more experienced than we are, and would need a fair amount of support if that was going to happen in the community.

If you have a look at the WHO recommendations, I noticed they talk about long acting benzodiazepines for withdrawal symptoms following cessation of alcohol. Again, I am suggesting to you, that there would be benefit in doing that in conjunction with someone who has special understanding of drug and alcohol issues during pregnancy. All of the teaching hospitals have specific clinics for that, and certainly the drug and alcohol resources, that is the ordinary drug and alcohol resources, would be more than happy to give you some advice over the telephone and certainly connect up with your patient to help that happen.

Elizabeth: Yes, I would really support that, Linda. I think that sudden detoxification can cause harm to both mother and baby and it really needs to be done under expert supervision.

Linda: IVF people.

Justine: About IVF specifically?

Linda: Well I always think that a person who is undergoing IVF is just a pre-conception person and therefore we must not forget that they are people we need to talk to about alcohol.

Justine: Yes. And that is really one of the big issues is the fact that if you are planning pregnancy, if you are going to a planning clinic, if they are going to take the time to actually plan, because we know that 50% of women do not plan pregnancy, but how many pregnancy plan their holidays? Is that what they say? It is really super important that they know that you know, I think the magic number is three months prior to pregnancy to start to really stop drinking. Or if you are trying, you should not be drinking, simple as that. So yes, it is definitely a question I get asked a lot when I am at the expos and people come up and say oh, we want to try for a baby and what should I tell my husband?

Linda: You know those people who start their folic acid. With their brain turned on, they should stop drinking at the same time.

Elizabeth: Yes, yes. That is great. And I mean I think that is a good point Linda that this whole discussion of alcohol has to be in the context of wanting a normal, a healthy pregnancy and a happy outcome. And therefore we stress that these are routine questions and that we are going to ask about drugs and alcohol and prescription drugs and smoking and we are going to warn them about cheese and pate and all the things that we do for pregnant women. And really just try and encourage them to you know, for this very short period of their lives to acknowledge it may have good outcomes, better outcomes for their offspring. And I suppose what we do not know is the epigenetic effects, and from experimental models we are now starting to see that alcohol can have all sorts of effects on switching genes on and off which have impacts on later cardiovascular and other disorders. So, yes, if you can do it once you decide you want to try and get pregnant, go off that contraception and stop drinking alcohol should be the message.

Justine: And so it says here, can a GP refer any time during pregnancy? Yes, absolutely. Any time they can come in to the Get Healthy Service. You are very welcome to refer at any gestational age.

Linda: I think the big advantage of the Get Healthy in Pregnancy Service is you have got the time, you have got the trained personnel. It is free of charge and it is not just a one off, it has got those 10 sessions. And it comes with information.

Justine: And it is actually part of New South Wales Health provision, so it is totally factual. It is not like going on to a blogger and getting an opinion, these women and men who are our coaches are sometimes dual trained. Some of them are masters in dietetics and sometimes they are also an exercise physiologist. So we know that you are actually getting good advice for your women who need the help at this time and it is obviously never going to overtake what you say, it is just going along with what you say. So they cannot prescribe as we said, but they are just supporting the messages that you have initiated.

Linda: In addition to the resources that Elizabeth has mentioned and obviously the connection to the Get Healthy in Pregnancy program, there are some references and resources on the screen right now that you might find of some value and you will be able to access this again after this program. I think you would agree that this talk has improved our understanding of this issue. I think we do understand better the rates of alcohol use in pregnancy in Australia and the risks of prenatal alcohol exposure for our patients and their children. I think we have looked at identifying opportunities for discussion with our patients and the harms of alcohol use in pregnancy, and we have been exposed to the advice contained in the National Guidelines. We looked at using the Audit C tool to screen patients and identify their level of risk and need for support brief intervention, or referral to specialised services. And we certainly have had lots of discussion about the benefits of the free Get Healthy in Pregnancy Alcohol Abstinence program.

Sammi: That is great, thank you so much Linda. And thank you also Elizabeth and Justine for joining us tonight and also to everybody online. We do hope you have enjoyed the session and if you have any more questions, please do email them through to us. We will get back to you offline. So thank you and enjoy the rest of your evening.