FETAL ALCOHOL SYNDROME (FAS) PRIMARY PREVENTION THROUGH FAS DIAGNOSIS: II. A COMPREHENSIVE PROFILE OF 80 BIRTH MOTHERS OF CHILDREN WITH FAS

Susan J. Astley1,2,*, Diane Bailey2, Christina Talbot2 and Sterling K. Clarren2

1 Department of Epidemiology, School of Public Health and Community Medicine and
2 Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA 98195, USA

Received 1 December 1999; in revised form 11 April 2000; accepted 5 May 2000


    ABSTRACT
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
A 5-year, fetal alcohol syndrome (FAS) primary prevention study was conducted in Washington State to: (1) assess the feasibility of using a FAS diagnostic and prevention clinic as a centre for identifying and targeting primary prevention intervention to high-risk women; (2) generate a comprehensive, lifetime profile of these women; (3) identify factors that have enhanced and/or hindered their ability to achieve abstinence. The results of this study are presented in two parts. Objective 1 is summarized in the preceding paper and objectives 2 and 3 are summarized here. Comprehensive interviews were conducted with 80 women, who had given birth to a child diagnosed with FAS, to document their sociodemographics, reproductive and family planning history, social and healthcare utilization patterns, adverse social experiences, social support network, alcohol use and treatment history, mental health, and intelligence quotient (IQ). These high-risk women were diverse in racial, educational and economic backgrounds, were often victims of abuse, and challenged by mental health issues. Despite their rather harsh psychosocial profile, many demonstrated the ability to overcome their alcohol dependence over time. Relative to the women who had not achieved abstinence, the women who had achieved abstinence had significantly higher IQs, higher household incomes, larger more satisfactory social support networks, were more likely to report a religious affiliation, and were more likely to be receiving mental health treatment for their mental health disorders. The rate of unintended pregnancies and alcohol-exposed pregnancies was substantial. Key barriers to achieving effective family planning were maternal alcohol and drug use, lack of access to birth control and lack of support by their partner to use birth control. A FAS diagnostic and prevention clinic can be used to identify women at high risk for producing children damaged by prenatal alcohol exposure. Primary prevention programmes targeted to this population could lead to measurable reductions in the incidence of FAS.


    INTRODUCTION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
The fetal alcohol syndrome (FAS) is a permanent birth defect caused by maternal use of alcohol during pregnancy. FAS is characterized by pre- and/or postnatal growth deficiency, central nervous system (CNS) dysfunction and a unique cluster of minor facial anomalies (Clarren and Smith, 1978Go). Prevention of FAS requires targeting primary prevention interventions to women at the highest risk of producing children damaged by prenatal alcohol exposure. FAS studies consistently report that women who have had one child with FAS, and who continue to drink, have progressively more severely affected children with subsequent pregnancies (May et al., 1983Go; Davis and Lipson, 1984Go; Abel, 1988Go).

Although women who have one affected child often have more, to date there are no anticipatory biological or sociological markers that distinguish the mothers of children with FAS from other women who drink in pregnancy and bear normal or nearly normal children. Treatment of women for alcoholism during pregnancy probably comes too late to prevent brain damage in affected fetuses, even if the correct high-risk, alcoholic women are selected for therapy. While it would be ideal to identify and treat all alcoholic women prior to pregnancy, resources for such an effort are not available. However, each patient with FAS (as identified through a FAS diagnostic clinic) has a mother who has a proven ability to give birth to a child damaged by prenatal alcohol exposure. Focusing prevention efforts on this select and high-risk group of women could reduce the incidence of FAS births dramatically without overburdening the current healthcare and alcohol treatment system (Clarren and Astley, 1998Go).

A Cooperative Agreement with the Centers for Disease Control and Prevention (CDC) from 1992 to 1997 allowed the development of a FAS diagnostic clinic at the University of Washington to: (1) assess the feasibility of using a FAS diagnostic clinic as a centre for identifying and targeting primary prevention intervention to high-risk women; (2) generate a comprehensive, lifetime profile of their birth mothers as a first step in the development of a FAS primary prevention programme targeted to meet their needs; (3) identify factors that have enhanced and/or hindered the birth mothers' ability to achieve abstinence.

The methods and outcomes of this FAS diagnostic and prevention project are presented in two parts. In the first report, the objectives and methodology for the entire project and a summary of the project's success at identifying high-risk birth mothers through the diagnosis of their children (objective 1) have been made (Astley et al., 2000Go). In this second report, we present a lifetime profile of 80 women who gave birth to a child with FAS, and identify factors that enhanced and hindered their ability to achieve abstinence and/or practice effective family planning (objectives 2 and 3).


    METHODS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
A detailed presentation of the methods is given in the preceding paper (Astley et al., 2000Go). Briefly, the birth mothers of children with confirmed prenatal alcohol exposure and a diagnosis of FAS or static encephalopathy were identified retrospectively and prospectively through paediatric diagnostic clinics at the University of Washington and Children's Hospital and Regional Medical Center in Seattle, Washington. These clinics included the University of Washington FAS Diagnostic Clinic established through this Cooperative Agreement (Clarren and Astley, 1997Go; Clarren et al. 2000Go). The diagnosis of FAS or static encephalopathy/alcohol exposed was made using the clinical gestalt guidelines published by Sokol and Clarren (1989), or the 4-Digit Diagnostic Code created by Astley and Clarren (1997, 1999, 2000). Women were eligible to enrol if they had given birth to at least one child with a diagnosis of FAS or static encephalopathy as described above. They could be of any age or race and had to be a resident of Washington State at the time of study enrolment. Each woman participated in a 4-h structured personal interview developed to generate a lifetime, comprehensive profile of her sociodemographics, reproductive and family planning history, social and healthcare utilization patterns, adverse social experiences, social support network, alcohol use and treatment history, mental health, and intelligence quotient (IQ). The interview included 2044 questions. The questions focused on three time periods in the women's lives: (1) at the birth of the index child with FAS; (2) at the time of the interview; (3) over their lifetime. This study was reviewed and approved by the University of Washington Human Subjects Review Board.

Analysis
t-Tests and paired t-tests were used to compare outcomes between two independent or paired groups respectively when outcomes were measured on continuous scales. {chi}2-Tests and Fisher Exact tests were used to compare outcomes between two independent groups when outcomes were measured on nominal scales. Wilcoxon Signed Rank tests and McNemar tests were used to compare proportions between two independent or paired groups respectively, when outcomes were measured on ordinal scales.


    RESULTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Identification and enrolment of birth mothers
A total of 257 women were identified as potentially eligible to enrol in this study. They had given birth to one or more children with confirmed exposure to alcohol and a gestalt diagnosis of FAS (Sokol and Clarren, 1989Go) or a 4-Digit Diagnostic Code diagnosis of FAS or static encephalopathy/ alcohol exposed (Astley and Clarren, 1997Go, 1999Go, 2000Go). Of the 257 mothers, 92 were confirmed to be eligible to enrol in this study, 58 were confirmed to be ineligible and the eligibility of the remaining 107 remained unknown. Of the 92 mothers confirmed to be eligible, 80 (87%) were enrolled and interviewed. A more detailed summary of identification and enrolment can be found in Part I of this series (Astley et al., 2000Go).

Representativeness of the maternal and patient study populations
The maternal population that the FAS Diagnostic and Prevention Network (DPN) clinics will target for primary prevention efforts are the birth mothers of children with FAS and static encephalopathy who can be identified and located with reasonable effort and live within Washington State where they are eligible to receive social and healthcare services. This target population is defined by the eligibility criteria presented above for this study. Eighty of the 92 women (87%) confirmed to be eligible to enrol in this study were enrolled and interviewed. A more detailed summary of the representativeness of this study population is presented in Part I of this series (Astley et al., 2000Go). Based on the percentage of women interviewed (87%) and the profiles of the eligible women who did (n = 80) and did not enrol (n = 12), this study population is regarded as being highly representative of the target population.

Profile of the 80 children whose mothers were enrolled
A profile of the 80 children whose mothers were enrolled in the study is presented in Part I of this series (Astley et al., 2000Go). They were predominantly Caucasian, 7.8 years of age at the time of their diagnosis, with over half no longer living with their birth mothers at the time of the diagnosis. Eighty-nine per cent had a gestalt or 4-Digit Diagnostic Code diagnosis of FAS or atypical FAS (AFAS); the remaining 11% had a 4-Digit Diagnostic Code diagnosis of static encephalopathy/ alcohol exposed without the full FAS facial phenotype. These were the diagnostic outcomes used to determine the birth mother's enrolment eligibility.

Maternal sociodemographic and mental health profile
A comprehensive, lifetime profile of the 80 birth mothers was generated, documenting their sociodemographics, social and healthcare utilization patterns, adverse social experiences, and mental health (Tables 1, 2, 3 and 4GoGoGoGo respectively). Due to the volume of data collected, only selected portions of this profile are presented in this report. Briefly, these women were on average 21 years of age at the birth of their first child, 27 years of age at the birth of the index child, 35 years of age at the diagnosis of the index child, and 38 years of age at the time of study enrolment. The study population was predominantly Caucasian, closely resembling the racial distribution of Washington State with a slight over-sampling of Native Americans. Their children were on average 7.8 ± 5.9 (range 0.1 to 24.2) years of age at the time they were diagnosed. The average maternal IQ was 90.0 ± 15.2. Sixty-one per cent did not complete high school; 25% had some college education. Fifty-nine per cent had a gross annual household income of less than US$10 000 at the time of the interview; 78% were in this income bracket at the time of the index child's birth. Ninety-five per cent had been physically or sexually abused during their lifetime. Ninety-six per cent had one to 10 mental health disorders with the most prevalent being post-traumatic stress disorder (77%) and simple phobia (44%).


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Table 1. Selected sociodemographic characteristics of the 80 birth mothers
 

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Table 2. Maternal report of need for and access to social and health care services around the time of the index child's birth
 

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Table 3. Home placements and adverse experiences among the 80 birth mothers
 

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Table 4. Mental health profile of the 80 birth mothers
 
Maternal lifetime reproductive and family planning histories
The women's lifetime reproductive and family planning histories are presented in Tables 5 and 6GoGo respectively. At the time of the interview, these women had given birth to 272 children. Seventy-three per cent of each woman's live births were reportedly unplanned, 76% were reportedly exposed to alcohol. Mean parity and gravidity at the time of the interview was 3.4 ± 1.6 live births and 4.4 ± 2.1 conceptions respectively. The mean parity of the index child was 2.6 ± 1.5. Thirty-five of these women went on to have 61 additional children after the birth of their index child. These 35 birth mothers reported that 80% of the 61 children were unplanned and 75% were exposed to alcohol. Although the study did not include gathering outcome data on these subsequent births, it was known that at least six of these children were diagnosed with FAS. The 80 women on average reported not using any form of birth control during most (81%) of their pregnancies. When asked what form of birth control they would prefer if it were available to them free of charge, the most preferred method was Depo Provera (31.6%) followed by Norplant (16.5%), tubal ligation (13.9%), and the pill (10.1%).


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Table 5. Reproductive history of the 80 birth mothers
 

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Table 6. Family planning history of the 80 birth mothers
 
Maternal lifetime drug and tobacco use
Eighty-six per cent of the women reported using illicit drugs at some time in their lives, 40% reported use around the time of the birth of the index child and 9% reported current use (around the time of the interview) (Table 7Go). The most common drugs used were marijuana, ‘speed’/amphetamines and cocaine/‘crack’. Eighty-four per cent of the women smoked tobacco around the time of the index child's birth.


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Table 7. Lifetime drug and tobacco use of the 80 birth mothers
 
Maternal lifetime alcohol use and treatment histories
A large volume of data was collected on alcohol use and treatment, short summaries are presented in Tables 8 and 9GoGo. Briefly, these women were on average 15 years of age when they first started drinking, between 23 and 28 years of age when they were drinking maximally, 26 years of age when they first attempted to stop drinking, and 27 years of age at the birth of the index child. They reported drinking on average 9 fluid ounces (or 266 ml) of alcohol per drinking occasion just before the birth of the index child. Almost half of the women (47%) reported drinking daily at that time. While 84% reported that they felt that they had a problem with alcohol use, 94% reported they did not want to reduce their use, because it helped them cope, and 72% did not want to reduce, because they were in an abusive relationship; with 79% reporting that they were too depressed to do anything about it. The four most common reasons for not seeking alcohol treatment were that they did not want to give up alcohol (87%), that they were afraid they would lose their children (42%), that there was no one to take care of the children (40%), and that their partner did not want them to go to treatment (39%).


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Table 8. Alcohol use history of the 80 birth mothers
 

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Table 9. Alcohol treatment history of the 80 birth mothers
 
Of the 80 women interviewed, 41 reported that they were abstinent by the time their child was diagnosed with FAS or static encephalopathy. Abstinence was defined as ‘consumes no alcohol or consumes minimal quantities only on special occasions’. This is comparable to the definition of abstinence proposed by Cahalan et al. (1969) ‘drinks less than once a year or does not drink alcoholic beverages’. Fifty of the 80 women reported that they were currently abstinent (at the time of the interview). They had made, on average, six concerted attempts to stop drinking. Of the 80 women, 37 (46.2%) were still at risk of producing another child damaged by alcohol exposure at the time of the index child's diagnosis by virtue of still being fertile and actively drinking or at risk for drinking.

Contrasts between women who had and had not achieved abstinence
Contrasts between the 50 women who had achieved abstinence by the time of the interview and the 25 women who were not abstinent at this time point are presented in Table 10Go. The women who had achieved abstinence had, on average, significantly higher IQs, higher household incomes, larger more satisfactory social support networks, and were more likely to report a religious affiliation. While they were equally likely to have mental health disorders, those who had achieved abstinence were more likely to have received treatment for their mental health disorder(s). Those who had achieved abstinence reported higher levels of drinking just before the birth of the index child and were more likely to have parents who had problems with alcohol use. They were comparable in race, education, employment, adverse experiences such as physical/ sexual/emotional abuse, age at the interview, age at first abstinence attempt, age at first pregnancy, age at birth of index child, and age when first started drinking.


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Table 10. Selected contrasts between the 50 women who had achieved abstinence at the time of the interview and the 25 women who had not achieved abstinence
 
Contrasts between a woman's most and least successful abstinence attempts
Women were asked an identical set of questions about alcohol use and treatment during what they believed was their least successful abstinence attempt, most successful abstinence attempt, and the abstinence attempt closest to the birth of the index child. Of the 31 women who were abstinent at the time of the interview and reported a most and least successful abstinence attempt, the following were found to be significantly different between the two attempts. During their most successful attempt, they were on average 6 years older, more likely to be worried about the impact of their alcohol use on their health, receiving more support from their family, less likely to be employed, more likely to be dependent on public assistance for an income, more likely to be seeking treatment from an agency or person outside their home, more likely to have completed an inpatient treatment programme, more likely to have participated in an aftercare programme and more likely to attribute their success in stopping drinking to their desire/ readiness to stop and their religious beliefs. All other factors were comparable between their most and least successful sobriety attempts, including the amount and frequency they were drinking, whether or not they had a partner who was drinking, and the number of children they were caring for at the time.


    DISCUSSION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
The interviews revealed that this high-risk population of women was diverse in racial, educational, and economic background, they were often victims of abuse and challenged by mental health issues. Despite their rather harsh psychosocial profile, many demonstrated the ability to overcome their alcohol dependence over time. Many descriptions of the female alcoholic population have appeared in the literature (Jarvis, 1992Go). Despite repeated attempts to capture the essence of the ‘female alcoholic personality syndrome’ most have recognized the heterogeneity of the population (Beckman, 1984aGo,bGo). In comparing our population to the published profiles of women alcoholics, we find many similarities and some interesting contrasts.

Mental health
The co-occurrence of alcoholism with other mental health disorders has been widely recognized (Regier et al., 1990Go; Sheehan, 1993Go). Kessler et al. (1997) reported on patterns and correlates of psychiatric morbidity and co-morbidity based on data from the National Co-morbidity Survey, a nationally representative household survey of 8098 men and women between 18 and 54 years of age. Interviews were conducted face-to-face, with an 83% response rate. Diagnoses were made according to DSM-III-R criteria, using a modified version of the Composite International Diagnostic Interview (World Health Organization, 1990Go). Lifetime co-occurrence of mental health disorders among the subset of 299 women with diagnoses of alcohol abuse were as follows: post-traumatic stress disorder (10.5%), depression (30.1%), simple phobia (28.2%), social phobia (24.1%), antisocial personality (2.1%), agoraphobia (9.3%), generalized anxiety disorder (8.4%), mania (3.8%), and panic disorder (7.3%). The proportion of women with alcohol abuse who had a first onset of a disorder prior to the onset of alcohol abuse were as follows: post-traumatic stress disorder (10.5%), depression (30.1%), simple phobia (28.2%), social phobia (24.1%), antisocial personality (2.1%), agoraphobia (9.3%), generalized anxiety disorder (8.4%), mania (3.8%), and panic disorder (7.3%). Social phobia, simple phobia, depression, and drug dependence were highly predictive of subsequent development of alcohol abuse in Kessler's study population. In comparison, the prevalence of mental health disorders in our population of 80 women appeared to be much greater and more likely to precede the onset of their alcohol abuse (Table 4Go).

Physical/sexual abuse
Physical and sexual abuse is prevalent among alcoholic women. Covington (1982) reported that 12 to 53% of alcoholic women report incest or other childhood sexual abuse and up to 74% report some type of childhood or adult sexual abuse. Our study revealed that childhood and/or adult sexual abuse occurred in 73% of the 80 women. Almost all (95%) were sexually and/or physically abused during their lifetime. Women who suffer from abuse may become increasingly depressed, anxious, and fearful of violence in their lives (Root, 1989Go). This latter author suggested that many women who relapse following substance abuse treatment are unable to cope with ongoing physical or sexual abuse without using alcohol or other drugs, and contended that substance abuse treatment personnel need to be familiar with the syndrome of domestic violence and abuse, because intervention will be unsuccessful if issues of past and current abuse are not addressed during substance abuse treatment. Beckman (1980) reported that alcoholic women were more likely to report that they felt powerless and inadequate compared to non-alcoholic women, and stated that these findings support the contention that heavy alcohol consumption is a coping mechanism likely to be used by women to relieve feelings of helplessness and powerlessness (Beckman, 1984aGo). The use of alcohol and other drugs has become a way for women to deal with the emotional pain resulting from earlier abuse by someone close to them, someone they trusted (Covington and Surrey, 1997Go). Ninety-four per cent of the women in our study reported that they did not want to reduce their alcohol use because ‘alcohol helped them cope’. Seventy-two per cent reported that they did not want to reduce their alcohol use because ‘they were in an abusive relationship’ or ‘they were too depressed to do anything about it (79%).

Social support
Social support has often been reported in the literature as an important enabling factor in reduction of alcohol dependence. In a study of 400 Anglo-alcoholics in treatment for alcoholism, Beckman (1984b) reported that females who completed treatment were more likely to have greater social support for treatment entry. The 50 women who achieved abstinence in our study reported having significantly larger, more satisfactory social support networks, than the 25 women who failed to overcome their alcohol dependence. Their social support networks included family, friends, and service providers.

Alcohol treatment
In 1992, a survey was conducted of 79 Seattle and King County non-profit and for-profit alcohol and drug treatment agencies to assess the availability of gender-specific treatment for women (Seattle–King County Task Force for Chemically Dependent Women, 1993Go). The agencies reported that 33% of their clientele were women of whom 73% were Caucasian, 14% were African American, and 5% were Native American: 73% were between 21 and 40 years of age. Eighty-four per cent of the providers did not provide on-site childcare, 54% did not offer medical or mental health services at the agency site and 44% did not offer on-site recovery support groups such as Alcoholics Anonymous. When the providers were asked what they believed to be the major obstacles for women securing treatment, the top three barriers reported were childcare, money, and social stigma. These are certainly troubling statistics in the light of the data collected in our study. Ninety-six per cent of the 80 women had one or more mental health disorders and the women who received mental health treatment were significantly more likely to achieve abstinence than women with mental health disorders who did not receive treatment. Sixty to 70% of the 80 women reported that they were taking care of one or more children during their reported abstinence attempts. Women who achieved abstinence were significantly more likely to participate in an aftercare programme, like Alcoholics Anonymous. Women who had failed to achieve abstinence had significantly lower incomes.

Beckman and Amaro (1984) reported that, although the relative success of different types of alcoholism treatment has long been debated, there is some evidence that treatment programmes, regardless of their orientation, produce more positive and lasting outcomes than does doing nothing for the alcohol abuser. It is interesting to note that, while 39 of the 50 women who achieved abstinence in our study reported seeking help outside their home during their most successful abstinence attempt, only 31 reported being admitted to an inpatient and/or outpatient programme and only 26 reported completing the programme(s). Beckman and Amaro (1984) also reported that, to accept help for an alcohol-related problem, a person generally must first perceive the existence of the problem and be willing to attempt to control it. In our study, the women who achieved abstinence were significantly more likely to report concern for their health and a desire to stop drinking, than the women who did not achieve abstinence.

Beckman and Amaro (1984) reported that characteristics related to the individual that affect the person's ability to secure, and inclination to use, services include: (1) individual predisposing factors, such as age and ethnicity; (2) attitudes and beliefs regarding alcohol, treatment, and health; (3) personal enabling traits, such as personality characteristics and drinking and treatment history; (4) social enabling characteristics, such as childcare responsibilities, social support systems, and access to financial resources. The predisposing factors of age and ethnicity are immutable. Some mutable predisposing factors, such as education and income, may be changed through both policy and individual efforts, whereas other mutable predisposing factors, such as religion or marital status, are more often changed through individual decisions (Beckman, 1984aGo,bGo). In a study of moderately drinking women entering a programme for drinking reduction (Walitzer and Connors, 1997Go), contrasts between the 120 women who completed the treatment with the 51 women who did not complete the programme were comparable to the contrasts observed in our study (Table 10Go), despite the marked difference in the drinking levels of the two study populations. The moderately drinking women who did not complete treatment were significantly younger, more likely to have a racial background other than Caucasian, more likely to be single or divorced, had fewer years of education and reported more drinking per day at pretreatment, relative to the women who did complete the programme. Several factors that significantly differentiated the women who did, from those who did not, achieve abstinence in our study are potentially mutable (e.g. income, social support network, and mental health treatment).

Family planning
Avoiding alcohol use during pregnancy is just one of two ways to prevent FAS. The other is to prevent pregnancy during alcohol use. While the former reduces health risks to both mother and child, the latter is purported by some to be the more simple and immediate means to an end. Both approaches are complex and resistant to change. While society might view the alcohol use and unintended pregnancies of these women as problems in their lives, these women often perceive their alcohol use and pregnancies as partial solutions to their problems. They report that alcohol helps them cope with their often abusive and impoverished lives. Pregnancy and children not only qualify them for social and healthcare services they might otherwise not receive, they also fulfil an innate desire to bear and raise children. Based on the data collected in this study, it would appear that the women were more successful at avoiding alcohol use than preventing pregnancy. This could be due, in part, to the astonishing lack of access women have to contraceptives. In 1987, 22 years after the US Supreme Court affirmed the legality of contraceptive use in Griswold vs Connecticut, 57% of pregnancies nationwide were unintended (Forrest, 1994Go). In 1993–1994, new mothers in Washington State had approximately the same frequency of unintended pregnancies resulting in a live birth as the nation as a whole: 40% in Washington compared with 39% nationwide in 1988 (Brown and Eisenberg, 1995Go; Pregnancy Risk Assessment Monitoring System, 1996Go). The women in our study reported that 78% of their first live born children were the result of unintended pregnancies; 60% of them were exposed to alcohol. There are many reasons why a woman does not practice effective birth control. One is access to affordable birth control. In a 1998 survey conducted by the Office of the Insurance Commissioner, to determine the level of reproductive health benefit coverage in health insurance plans marketed in Washington State, 77% of the insurance plans paid for abortions while only 30% provided coverage for contraceptives. Worse yet, the percentage of individuals actually receiving coverage was lower; four out of five women do not have coverage for contraceptives (Senn, 1998Go). Lack of access was not the only reason that women in our study did not use birth control. They were equally likely to report that their alcohol and drug use interfered with their use of birth control and that their partners did not want them to use birth control. Only 10% reported that they felt birth control was wrong or against their religious beliefs. In fact, 78 of the 80 women reported using some form of birth control during her life (diaphragm, intrauterine device, cervical cap, pill, Depo Provera, Norplant, condoms, rhythm method or withdrawal) suggesting that few were opposed to birth control.

Current status of the Washington State FAS DPN primary prevention programme
The FAS DPN is currently working with Washington State to facilitate referral of high-risk women identified through the FAS DPN to appropriate primary prevention intervention services. Through this comprehensive approach to FAS diagnosis and prevention, we hope to reduce measurably the incidence of FAS in Washington State.


    ACKNOWLEDGEMENTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
We would like to thank the following individuals and agencies for their help in designing, implementing and analysing this study: Kathy Briggs-Jones, Serena Harris, Heather Grigg, Jill Crank, Washington State Department of Health, Washington State Department of Corrections, Seattle–King County Department of Public Health and all the collateral contacts who helped us identify and enrol the birth mothers. We extend our very sincere thanks to the birth mothers who so generously and openly contributed to this project in the hopes that they may help women in similar need. This study was supported by Cooperative Agreements U84/CCU-008707 and U59/CCU-006992 from the Centers for Disease Control and Prevention. Additional support was received from the Washington State Department of Social and Health Services, the Washington Chapter of the March of Dimes Birth Defects Foundation, the John B. Chavez Memorial FAS Fund and the Center on Human Development and Disability at the University of Washington.


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 ACKNOWLEDGEMENTS
 REFERENCES
 
* Author to whom correspondence should be addressed at: Children's Hospital and Medical Center, 4800 Sand Point Way N.E., CH-47, Seattle, WA 98105, USA. Back


    REFERENCES
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 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Abel, E. L. (1988) Fetal alcohol syndrome in families (Commentary). Neurotoxicology and Teratology 10, 12.

Astley, S. J. and Clarren, S. K. (1997) Diagnostic Guide for Fetal Alcohol Syndrome and Related Conditions: The 4-Digit Diagnostic Code, pp. 1–93. University of Washington Publication Services, Seattle.

Astley, S. J. and Clarren, S. K. (1999) Diagnostic Guide for Fetal Alcohol Syndrome and Related Conditions: The 4-Digit Diagnostic Code, 2nd edn pp. 1–111. University of Washington Publication Services, Seattle.

Astley, S. J. and Clarren, S. K. (2000) Diagnosing the full spectrum of fetal alcohol-exposed individuals: introducing the 4-Digit Diagnostic Code. Alcohol and Alcoholism 35, 400–410.[Abstract/Free Full Text]

Astley, S. J., Bailey, D., Talbot, C. and Clarren, S. K. (2000) Fetal alcohol syndrome (FAS) primary prevention through FAS diagnosis: I. Identification of high-risk birth mothers through the diagnosis of their children. Alcohol and Alcoholism 35, 499–508.[Abstract/Free Full Text]

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Brown, S. S. and Eisenberg, L. eds (1995) The Best Intentions: Unintended Pregnancy and Well-Being of Children and Families. Institute of Medicine, National Academy Press, Washington DC.

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