Prevention of fetal alcohol spectrum disorders must include maternal treatment

To the Editor: There is an increased focus on fetal alcohol spectrum disorders (FASD) in Australia with population prevention strategies and innovative work to improve detection and diagnosis of FASD, particularly in Indigenous communities.1 However, there has been insufficient focus on treatment for women with alcohol dependence, and this is where risk of harm is highest.

Despite evidence to suggest a decline in the number of Australian women drinking during pregnancy, the proportion drinking at high levels remains unchanged and treatment coverage for this group poor.2 It is estimated that 3.7% of Australian women will meet the criteria for an alcohol use disorder in a given year,3 yet only 8.5% will obtain any treatment.4 Given that only a minority of these women will be pregnant, it suggests even poorer coverage for this group. Antenatal care is also compromised. Hospital data suggest that women with alcohol use disorders during pregnancy present late to antenatal care and are often unbooked at delivery.5 Thus, targeted interventions and treatments are urgently required.

A lack of ambulatory services and dedicated detoxification facilities that will admit pregnant women, services that accommodate women with other children and the substantial stigma associated with alcohol use in pregnancy all remain significant barriers to treatment.

Unlike opioid substitution therapy, no pharmacological interventions, other than vitamins, are available for pregnant women who are alcohol dependent. Effective psychosocial approaches are also not routinely available. There is a need for high-quality intervention research.5

In addition to public health initiatives to prevent FASD, identification and treatment of alcohol dependence in pregnancy must be improved. Midwives, obstetricians and other professionals in primary and acute care need appropriate training in routine screening for alcohol use. Availability and access to services need to be improved, with clear pathways to care.

We know outcomes are far worse for women with alcohol dependence and their babies alike, with higher than expected rates of morbidity and mortality in both groups.1 Alcohol dependence is a chronic relapsing disorder, and more needs to be done to treat women as a component of any effort to prevent FASD. Without this, prevention campaigns are neglecting one of the most vulnerable and high-risk groups in society; surely we can and must do much better than that.