Reducing the Incidence of FASD: What Have We Learned?

By Iris Smith, Ph.D.

The first paper detailing the clinical features of prenatal alcohol exposure in the United States was published in 1973.¹ Early studies of prenatal alcohol exposure focused on  physical and neurological abnormalities associated with Fetal Alcohol Syndrome (FAS), a categorical diagnosis. Recent research has increased our understanding of the full spectrum of consequences resulting from prenatal exposure, now known as fetal alcohol spectrum disorder (FASD). In the 50 years since FAS was first identified, the increased knowledge of the underlying mechanisms and potential risk factors associated with prenatal exposure to alcohol has helped us to better understand the potential effects of other commonly misused drugs including cocaine, methamphetamine, cannabis, and synthetic opioids. The global prevalence of FASD is now estimated to be 7.7 per 1,000 births and is a leading cause of developmental disorders.² However, despite the proliferation of research on child outcomes associated with maternal alcohol use during pregnancy, there are relatively few evidence-based strategies to prevent it. 

Alcohol use during pregnancy increases the risk of a poor pregnancy outcome and there is no consensus on whether there is a “safe” threshold of alcohol use by pregnant women. The primary FASD prevention foci are people who are sexually active, within the childbearing age range, pregnant or planning to become pregnant (i.e., not currently using contraceptives). A history of regular alcohol use or diagnosis of a substance use disorder (SUD) and previous FASD birth are at highest risk. Universal prevention strategies have consisted of educational strategies to increase awareness of the risks of alcohol consumption during pregnancy such as warning labels on alcoholic products, warning signs, posters, media campaigns, and community wide promotional campaigns. Evidence of the effectiveness of universal approaches has not been encouraging. A systematic review of FASD prevention approaches concluded that universal awareness campaigns did not seem to be effective in reducing the risk of an alcohol exposed pregnancy (AEP). However, the more individualized and tailored the interventions were the more effective they were. Selected or indicated strategies directed at women at highest risk or conducted in environments where alcohol use was prevalent were more likely to motivate behavior change. Motivational interviewing techniques have also shown promise in changing behavior, particularly when integrated into primary care or prenatal clinic settings.^{3, 4}

The recent rise in prenatal opioid exposure has led to an increase in punitive policy approaches to discourage drug use during pregnancy. These policies include mandated reporting of alcohol or drug use to law enforcement or social welfare and civil commitment. A review of U.S. state policies from 1970-2013 found that the number of states that have enacted punitive policies regarding alcohol use during pregnancy increased from 1 in 1974 to 43 in 2013. The number of states that defined alcohol use during pregnancy as child abuse/neglect increased by 40% between 2003 and 2012, while the number of states that gave women priority for substance abuse treatment did not increase. Punitive policies have the potential to discourage women from seeking prenatal care or SUD treatment, increasing the potential harm to both mother and child.⁵ A recent study on the effects of state-level policies that treat prenatal substance use as child abuse or neglect on the incidence of neonatal withdrawal syndrome (NAS), maternal narcotic exposure and substance use treatment admissions for pregnant women found no evidence that state punitive prenatal substance use policies reduce rates of NAS or maternal narcotic exposure at birth.⁶ 

Evidence-based prevention strategies that support and motivate behavior change are well worth the effort. FASD is preventable and costly over the lifespan of an FASD individual. It is estimated that the annual cost for all individuals with FASD in the United States ranges from $1.29 billion to 10.1 billion, while an intervention program focused on women who previously gave birth to a child with FASD could cost as little as $20,200 per case prevented, saving society $2,235,800 based on the present discounted value of life-time cost.⁷ 

Resources

Chang G (2023) Reducing Prenatal Alcohol Exposure and the Incidence of FASD: Is the Past Prologue?  Alcohol Research 43(1); pg. 2.  PMCID:  PMC10127686

Flannigan K, Coons-Harding KD, Anderson T, Wolfson L, Campbell A, Mansfield M, Pei J (2020).  A Systematic Review of Interventions to Improve Mental Health and Substance Use Outcomes for Individuals with Prenatal Alcohol Exposure and Fetal Alcohol Spectrum Disorder.  Alcohol Clinical Experimental Research 44(12); pg. 2401-2430.  PMCID:  PMC7839542

Floyd RL, Weber MK, Denny C, O’Connor MJ (2009) Prevention of Fetal Alcohol Spectrum Disorders.  Developmental Disabilities’ Research Reviews 15(3); pg 193-199.

Greenmeyer, Popova S, Klug MG, Burd L (2020) Fetal Alcohol Spectrum Disorder:  A Systematic Review of the Cost and Savings from Prevention in the United States and Canada.  Addiction; 115(3); pg. 409-417. https://doi.org/10.1111/add.14841

Grubb M, Golden A, Withers A, Daniella Vellone D, Young A, McLachlan K (2021).  Screening Approaches for Identifying Fetal Alcohol Spectrum Disorder in Children, Adolescents, and Adults:  A Systematic Review.  Alcohol Clinical and Experimental Research 45(8); pg. 1527-1547.

Jacobsen B, Lindemann C, Petzina R, Verthein U. The Universal and Primary Prevention of Fetal Alcohol Spectrum Disorders (FASD): A Systematic Review. Journal of Prevention 43(3); pg. 297-316. doi: 10.1007/s10935-021-00658-9. Epub 2022 Feb 5. PMID: 35286547; PMCID: PMC9114092