Impact of the CHOICES Intervention in Preventing Alcohol‐Exposed Pregnancies in American Indian Women

Abstract

Background Fetal Alcohol Spectrum Disorders (FASD) comprise a continuum of lifelong outcomes in those born prenatally exposed to alcohol. Although studies have shown no differences in rates by race, FASD is of particular concern for American Indian communities. One tribally-run prevention program is the Oglala Sioux Tribe (OST) CHOICES Program, which is modeled after the evidence-based CHOICES program that was focused on preconceptional prevention of alcohol-exposed pregnancy (AEP) by reducing risky drinking in women at-risk for pregnancy and/or preventing unintended pregnancy. Methods The OST CHOICES Program was made culturally appropriate for American Indian women and implemented with three communities, two on the reservation and one off. Data on drinking, sexual activity, and contraception use were collected at baseline and 3- and 6-months post-intervention. Data were analyzed using descriptive statistics, one-way ANOVA, and a random intercept generalized estimating equation (GEE) model. Results A total of 193 non-pregnant American Indian women enrolled in the OST CHOICES Program, and all were at-risk for AEP because of binge drinking and being at-risk for an unintended pregnancy. Fifty-one percent of participants completed both 3- and 6-month follow-up. Models showed a significant decrease in AEP risk from baseline at both 3- and 6-month follow-ups, indicating the significant impact of the OST CHOICES intervention. Women in the OST CHOICES Program were more likely to reduce their risk for AEP by utilizing contraception, rather than decreasing binge drinking. Conclusions Even with minor changes to make the CHOICES intervention culturally and linguistically appropriate and the potential threats to program validity those changes entail, we found a significant impact in reducing AEP risk. This highlights the capacity for the CHOICES intervention to be implemented in a wide variety of settings and populations.

A systematic review of prevention interventions to reduce prenatal alcohol exposure and fetal alcohol spectrum disorder in indigenous communities

“… Community: education and policy strategies High risk groups: Screening, targeted messages, referral for alcohol abuse Women identified through screening: Case management enhanced by brief intervention based on MI Number of children born with FASD Alcohol consumption: Frequency, Times “high” or drunk, binge drinking (Three drinks or more per occasion per day) Birth control status Overall, 69.5% of the time ( n = 105) fetuses were protected from PAE either by using birth control while drinking (39%), not drinking and using birth control (18.1%), or not drinking and not using birth control (12.4%) Further results are not reported due to high loss to follow-up from baseline ( n = 115) to 6 months ( n = 39) and 12 months ( n = 37). JD Hanson et al, 2017 [ 31 ] US American Indian women from two reservation sites and one urban site ≥18 years old, sexually active and fertile Non-pregnant women All participants were at risk of AEP (4 or more drinks per occasion or 8 or more drinks per week and not using any contraception or using a method incorrectly or inconsistently) Single cohort study with surveys at baseline, and three and six months post-intervention Oglala Sioux Tribe (OST) CHOICES Program was delivered to all participants (2– 4 sessions) The intervention included MI techniques delivered by trained interventionists to encourage participants to decrease binge drinking and increase birth control use to reduce the risk of AEP The program supported participants to: Set goals related to alcohol use and contraception use; Complete daily diaries to track alcohol use, sexual activity and birth control use; and seek health practitioner support for birth control through referrals Proportion of women at risk of AEP (defined as per the inclusion criteria, along with the proportion of participants pregnant at follow-up) Alcohol consumption: Volume, frequency, binge episodes Contraceptive use: Use of effective birth control and sexual activity Significant reduction in AEP risk from baseline (100%) to three months (exact value not provided, p value not stated), and six months (exact value not provided, p value not stated) Selective Strategies P Bridge, 2011 [ 27 ] Australia, Ord Valley in remote North- Western Australia Five target groups 1. All Aboriginal antenatal clients attending Ord Valley Aboriginal Health Service (OVAHS) 2.…”

“…All selective and indicated strategies used case-management and/or screening for alcohol use with brief intervention and/or referral to specialised treatment. In addition, three of these studies [ 28 , 30 , 31 ] included principles of motivational interviewing (MI). Interventions were delivered either face-to-face, by telephone or via the internet.…”

The Importance of Intimate Partner Violence in Within‐Relationship and Between‐Person Risk for Alcohol‐Exposed Pregnancy

“…The current findings support the notion that IPV, and other (third‐variable) predictors that may relate to both AEP and substance use, may warrant special attention in AEP prevention curricula, as IPV related to declines in both outcomes preferred over AEP: nonpregnancy and nAEP. Most preconceptual short‐term AEP interventions demonstrate improvement in birth control use (e.g., Hanson et al., ; Ingersoll et al., , ; Wilton et al., ), indicating AEP prevention through these programs is mostly due to nonpregnancy outcomes. Variables contributing to maintenance of alcohol use, or contexts in which substance use and low birth control use are part of a larger system of lack of control or autonomy, might need emphasis outside of the personal feedback, motivational interview, or self‐guided behavioral change formats, particularly for women who become pregnant.…”

“…Success of preconceptual AEP prevention programs is typically defined as either postprogram decrease in alcohol use or an increase in birth control. These programs do achieve both of these aims (Floyd et al., ; Hutton et al., ), but have more success in increasing birth control than reducing alcohol use (e.g., Farrell‐Carnahan et al., ; Hanson et al., ; Wilton et al., ). In other words, programs are more successful at reducing the number of overall potential pregnancies potentially exposed to alcohol, compared to reducing the amount of alcohol consumed that may affect the remaining pregnancies.…”

Prevalence of alcohol use in pregnant women with substance use disorder

“…Given the known long-term effects of prenatal alcohol exposure and updated prevalence rates of FASD, continued efforts to decrease drinking during pregnancy are needed to reduce the long-term risk for developmental disorders for all women, including those with OUD. Additional public health efforts should be devoted to preconceptional prevention of alcohol-exposed pregnancies by reducing risky drinking and/or use of effective contraception in women at risk, such as that which has been demonstrated in the CHOICES Program (Hanson et al, 2017;Velasquez et al, 2017). Given high unintended pregnancy rates in women with SUD, additional efforts should be devoted to effective family planning services.…”