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Facing the Challenges:

Healthy Child Development

Level 2 Toolkit:

Interdisciplinary MAINPRO CME for Family Physicians and other Primary Healthcare Providers



Editorial Steering Committee

Patricia Mousmanis, MD (Coordinator)

Ann Alsaffar, RN

Wendy Burgoyne

Claudette Chase, MD

Niki Deller

Danusia Gzik, MD

Laurie C. McLeod

Margaret Munro, MD

Ontario College of Family Physicians Representative

Lena Salach


Ann Alsaffar, RN

Ed Bader, MA

Sonya Bianchet

Teresa Carter

Patricia Fenton

Diane de Camps Meschino, MD

Sophie Grigoriadis, MD

Sarah Landy, PhD Psych

Chris Long

Margaret Leslie

Deana Midmer, RN, EdD

Joanne Morrissey

Dr. Peter Neiman

Debbie Nesbitt-Munroe

Alice Ordean, MD, MHSc

Susan Ramsay

Linda Rankin

Paula Ravitz, MD

Ruth Schofield

William J. Watson, MD

York Region Health Services

Tara Zupancic

Authors, Aboriginal Chapter

Marion Maar

Claudette Chase

Laurie C. McLeod

Margaret Munro

Aboriginal Panel

Cathy Alisch, Ontario Métis Aboriginal Association

Tracey Antone, Chiefs of Ontario

Carmen Blais, Nishnawbe-Aski Nation

Jane-Ann Burningfield, OFIFC
Ida Copenance, Treaty 3

Deanna Jones-Keeshig, Independent First Nations

Ulrike Komaksuulikask, Pauktuutit Inuit Women’s Association

Colleen Maloney, Ontario Native Women’s Association

Debra Pegamahgabow, Union of Ontario Indians

Monique Raymond, Métis Nation of Ontario
Lisa Tabobondung, Association of Iroquois and Allied Indians

Toolkit Reviewers

Nadia Hall

Amandeep Hans, MD

Linda Yolles, MD CCFP

Chris Long

For More Information Please Contact:

Ontario College of Family Physicians

357 Bay Street, Mezzanine Level

Toronto, ON M5H 2T7

Tel: 1-416-867-9646

Fax: 1-416-867-9990

Please note that programs, services and guidelines may change, therefore the reader is encouraged to consult current sources of information.

The information herein reflects the views of the authors and no official endorsement by the government of Ontario is intended or should be inferred.

Table of Contents


Section 1: Antenatal Assessment

Antenatal Psychosocial Health Assessment: The ALPHA Forms

Section 2: Substance Use in Pregnancy

Substance-using Pregnant Women

Nursing Perspective: Substance-using Pregnant Women

Section 3: Post Partum Mood Disorder

Interpersonal & Intrapsychic Developments of Pregnancy

Perinatal Depression and Anxiety

Perinatal Depression and Anxiety Summary

Decision Tree for Post Partum Mood Disorder

Post Partum Mood Disorder - Patient Perspectives

How to Talk to New Moms with Post Partum Mood Changes

What New Mothers Need from their Moms

Nursing Perspective: Postpartum Depression

Interpersonal Therapy for Treatment of Postpartum Depression

Section 4: Attachment

Attachment Patterns and their Contribution to Child Development and Adult Functioning

Nursing Perspectives: Attachment

Section 5: Developmental Issues

Developmental Assessment

Behavioural Manifestations of Autism in the First Year of Life

Fetal Alcohol Spectrum Disorder

Environmental Checklist

Section 6: Aboriginal Families

Healthy Child Development for First Nations, Métis and Inuit People

Section 7: Adoption

Primary Health Care and Adoption

Section 8: Fathering

Role of Fathers in Child Development

Information for New Dads

Section 9: Literacy

Early Childhood Literacy

Early Learning Literacy Guide

Promoting Literacy in the Physicians Office

Additional Literacy Services

Appendix 1: ALPHA Provider Form and Self Report
Appendix 2: Red Flags Developmental Reference Guide
Appendix 3: Playing it Safe: Childproofing for Environmental Health
Appendix 4: Ontario Antenatal Record 2005
Appendix 5: Guide to Ontario Antenatal Record 2005

Appendix 6: Pregnancy-Related Issues in the Management of Addictions


The Ontario College of Family Physicians (OCFP) has provided Continuing Medical Education workshops for its members since 1994. The Peer Presenter Program has facilitated an exchange of information and expert knowledge in clinical areas for professionals such that local community values are respected. The Healthy Child Development program was initiated in response to the Early Years Report published in April 1999 by Dr. J Fraser Mustard and the Honourable Margaret McCain. A multidisciplinary steering committee was assembled to provide input for the content of the curriculum and to create an innovative educational initiative.

In October 2000, the OCFP launched the Healthy Child Development Peer Presenter Program. Over thirty family physician peer presenters were trained to deliver the core curriculum content in their home communities by partnering with local service providers such as public health nurses, speech therapists, early child educators and mental health experts. This innovative project has reached over 4,000 health professionals in Ontario, across Canada and around the world. A teaching manual was created by the faculty at McMaster University that has become a core curriculum unit in the training of medical students and residents at several medical schools. In communities across Canada, there have been numerous requests for follow up advanced workshops to build on the material contained in the “Healthy Child Development: Improving the Odds” CME Toolkit Manual.

In 2004, the OCFP embarked on an ambitious challenge to provide more in depth coverage of the topics contained in the original manual while at the same time providing current up to date information that was relevant to health care professionals. A new steering committee was created to identify key areas that were relevant to family physicians, family practice nurses, public health nurses, nurse practitioners, midwives, social workers, and early childhood educators. Key expert authors were commissioned to write detailed chapters that would provide new research evidence, diagnostic pearls and management techniques to clinicians of all disciplines.

“Healthy Child Development: Facing the Challenges” is a manual that brings together information about child development, such as the role of the father, mood disorders in pregnancy, substance use in pregnancy, fetal alcohol spectrum disorder and relevant information about adoption and attachment. The important issues facing the Aboriginal people are explored in this new manual to help educate health care professionals on the history and cultural traditions of the Aboriginal community. Information about diagnostic tools as well as literacy are explored in depth.

The Ontario College of Family Physicians plans to bring this new program to various communities throughout the province by training a new set of peer presenters who will go back to their home communities and work closely with local community resources to improve service delivery to all families with children. The peer presenters will be trained in teams representing different disciplines to enhance service integration and interdisciplinary practice. This new “Facing the Challenges” manual will be provided as a resource to participants who attend these workshops.

Section 1: Antenatal Assessment

Antenatal Psychosocial Health Assessment:

The ALPHA Forms

Author: Deana Midmer

Chapter Objectives

  • To outline the development of the ALPHA Forms.

  • To identify issues in using the ALPHA Forms.

  • To describe antenatal psychosocial health issues associated with adverse postpartum outcomes.

  • To outline interventions to deal with antenatal psychosocial health issues in order to forestall the development of problematic postpartum outcomes.


Recent national guidelines in Canada and the U.S. have stressed the importance of antenatal psychosocial health assessment as a part of comprehensive obstetrical care. The ALPHA Forms were developed as tools to facilitate the collection of psychosocial data during pregnancy in a structured, logical, and time-efficient manner. The ALPHA Form is available in a provider-completed or self-report version.

Purpose of the ALPHA Forms

The forms contain questions that focus on antenatal factors that have been found to be associated with problematic postpartum outcomes. These adverse outcomes include: child abuse, or child endangerment, (CA); woman abuse, or intimate partner violence, (WA); postpartum depression, or postpartum mood and anxiety disorders, (PPD); couple dysfunction (CD); and physical illness in the infant (PI).

Development Process

An interdisciplinary group of obstetrical care providers (The ALPHA Group) began to meet in 1989 to explore the area of psychosocial assessment in pregnancy. We first surveyed family physicians to determine their current antenatal assessment strategies, the importance they ascribed to the adverse outcomes during the postpartum period, and their views on using a specially designed assessment tool to help them interview around these issues. Results indicated that they assessed sporadically yet attributed high importance to adverse postpartum outcomes; they displayed a keen interest in using a comprehensive tool (Carroll et al, 1994). Subsequently, we conducted a comprehensive and critical literature review to identify the antenatal factors associated with the problematic postpartum outcomes (Wilson et al, 1996).

Development of the Forms

The initial version of the ALPHA Form was developed as a provider-completed form. We tested the tool in focus groups of providers from different disciplines (medicine, midwifery, nursing) and used their feedback to modify the form further (Reid et al, 1998). We also developed a Provider’s Guide (Midmer et al, 2003) and a training video (Midmer, 2003). Because of feedback from pregnant women and nurses, we developed a self-report version of the form and tested it against the provider version on P.E.I. (Midmer, 2004). This study indicated that both versions of the form performed well, with equal utility, yield and provider and consumer satisfaction.

Concurrent with the ALPHA development process, the Ontario Medical Association (OMA) was revamping the Ontario Antenatal Record (OAR) it produces and disseminates. The ALPHA group presented to the OMA committee, and lobbied for more space on the OAR for psychosocial information. Consequently, the most recent iteration of the OAR has a check-off box for psychosocial issues, with headings that reflect the headings on the provider ALPHA Form. Using the ALPHA Form facilitates the completion of this section on the OAR and provides the practitioner with a rich history of the woman’s life situation. A detailed overview of the ALPHA development process has been reported elsewhere (Midmer et al, 2002).

A randomized trial was held in Ontario with family physicians, obstetricians and midwives. After agreeing to participate in the study, providers were randomized into an intervention group, who used the ALPHA form during prenatal care and a control group, who provided usual care. Results indicated that ALPHA group providers were more likely than control providers to identify psychosocial concerns (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.1-3.0; p=0.02) and to rate the level of concern as ";high"; (OR 4.8, 95% CI1.1-20.2; p=0.03). ALPHA group providers were also more likely to detect
concerns related to family violence (OR 4.8, 95% CI 1.9-12.3; p=0.001).
Using the ALPHA form helped health care providers detect more psychosocial
risk factors for poor postpartum outcomes, especially those related to
family violence (Carroll et al, 2005).

The Different ALPHA Versions

In the left column, the provider-completed ALPHA Form contains suggested questions relating to the antenatal factors associated with adverse outcomes. The adverse outcomes are abbreviated after each antenatal factor. Bold italics indicate a good association; regular print indicates a fair association. Space on the right is available for notes. There is a checklist of resources at the end of the form to facilitate the identification of appropriate interventions.

The self-report contains the same antenatal items that have been formatted either with a ranking scale or with a yes/no response with room for comments. The associations are not included on the form but are included in the provider recap sheet. This sheet also includes the checklist of resources and space for documentation.

Both versions can be found in the appendices. They are also available at http://dfcm19.med.utoronto.ca/research/alpha.

Using the Forms

Interviewing Process

The provider version can be completed in one session of about 20 minutes or over several prenatal visits. The woman should be advised in advance that her next appointment would be longer because of the assessment. Providers can bill for counseling/psychotherapy when appropriate. The self-report version can be given to the woman to complete at the end of a visit or when she is waiting before a visit. It is not advisable for the woman to take the form home or to complete it if she is waiting with her partner. Some of the questions are very confidential in nature or relate to sensitive couple issues.

It is recommended that the form be completed after 20 weeks gestation. It is helpful to normalize the interview process by indicating that current practice is to ask all pregnant women about the psychosocial issues in their lives. Feedback from women in the pilot study and the study on P.E.I. revealed that they enjoyed the interview process and that it enhanced the provider’s understanding of their life situation.

Problem Identification

The forms serve as means to identify antenatal issues that may become postpartum problems. Early problem identification and its unique situational components can lead to greater understanding and tailoring of care. Providers can collaborate with pregnant women around decision-making and the identification of the best intervention strategies.

Grouping of Factors

The antenatal factors have been grouped into categories. These are: Family Factors, Maternal Factors, Substance Abuse, and Family Violence. The factors are arranged in order from less-to-more sensitive areas of inquiry. This facilitates the provider’s development of an interviewing rapport and rhythm with the pregnant woman.

Issues of Confidentiality

Information elicited may be very confidential in nature. Except in the case of child abuse, which must be reported to children’s protective services, careful consideration and permission-seeking should occur before information is shared with others. It would be appropriate to share information with the other members of the health care team, including the family physician, obstetrician, pediatrician, and perinatal nursing staff.

Causality is NOT Implied

The antenatal factors are only associated with problematic postpartum outcomes. If an antenatal factor is identified, the woman may not experience an adverse outcome.

Identification of Resources

It is incumbent on providers to identify resources that are appropriate and available. Smaller communities may not have extensive resources, or may have resources with long waiting lists or that are some distance away, making it difficult or impossible for some women to attend. Some resources, though readily available may not be culturally appropriate.

Cultural Competence

Each culture has a rich social fabric. In some cultures, disclosure of psychosocial issues is rare and discouraged, and the use of outside resources is frowned upon. In other communities, elders are often arbiters and mediators. If an antenatal factor is disclosed, it would be appropriate to ask the women, “In your culture, how is this issue managed/handled?” “Who would you tell about this problem?”


Care must be taken when using interpreters. Because of the personal nature of the questions, it is advisable to use trained women interpreters. However, in some instances, because of the close inter-connectivity of some cultural groups, women may be reluctant to disclose sensitive issues to an interpreter she may meet in social situations. Using an interpreter who speaks the woman’s language but does not share her culture would be most appropriate. If interpreters are not available, it is wise to use non-family members and avoid using the woman’s spouse or children. Before beginning the ALPHA assessment, it is appropriate if the interpreter introduces herself, normalizes her presence at the interview, and assures the woman that the discussion will be kept private and confidential, in all areas, except in the area of child abuse.

Antenatal Factors

Lack of Social Support(CA, WA, PD)

In its broadest sense, while being modified and reshaped by culture, ethnicity, and family of origin, social support reflects an individual’s sense of belonging and safety with respect to a caring partner, family or community. Insufficient social support during pregnancy is characterized by isolation; lack of help when dealing with daily tasks, stressful events, or crises; and lack of social, instrumental, and/or emotional support from a spouse, close friend or family member.

Women who have recently relocated, immigrated or sought refuge in a new community may experience a significant lack of social support. The separation from their country of origin or from their cultural community may compound feelings of isolation. A lack of literacy in English or French may further increase their sense of disconnection.

Recent Stressful Life Events(CA, WA, PD, PI)

Stressful events are those life experiences that require some degree of adaptation with a resultant depletion of emotional reserves. These may include negative events such as financial problems, job loss, illness/death of a loved one, legal problems, and/or household or work moves. Joyful events, such as marriages in the family or promotions and/or other opportunities at work can also be stressful and require adaptation by the young family.

If over-stressed, individuals may resort to the stress-reduction behaviours modeled in their family-of-origin, such as social withdrawal, abuse of alcohol or other substances, somatization, and/or inappropriate or violent venting of anger and frustration. The movement into parenting can often cause problematic behaviours witnessed in the family of origin to begin to surface.

Couple Relationship Dysfunction (CD, PD, WA, CA)

The strongest predictor of a good postnatal relationship is the quality of the relationship antenatally. How couples rate their relationship antenatally is strongly correlated with the way they rate their relationship in the first postnatal months. Most marriages or similar relationships in the postpartum period become more traditional by virtue of the woman’s increased emotional and financial dependence on her partner. Because of this shift in the spousal structure, women who hold less traditional role expectations may experience more marital dissatisfaction in the postpartum period.

Late Onset Prenatal Care (WA)

If a primiparous woman does not start prenatal care until the third trimester, this is a “red flag” for concern because of the strong association with abuse by her partner. It is important to inquire why there was a delay in seeking prenatal care. It is also important to identify any cultural factors that impact on the woman’s decision to attend for care. If a woman indicates she is seeking care late because of a recent move into the community, this should be explored further. Frequent moves can be part of a pattern of social abuse.

Refusal to Attend for Prenatal Education (CA)

If a primiparous woman refuses to attend prenatal classes or quits prenatal classes, there is an association with child abuse. However, as with all maternal factors, it is important to look at the context of a woman’s life situation before drawing conclusions about her risk for postpartum difficulties. A woman may not attend classes because she or her partner does not speak the language in which they are given in her community. She may not choose to attend because she is single and classes are only offered to couples; because she is in a same-sex relationship and classes are heterosexual in orientation; because her partner refuses to attend or does not let her attend; or because she can not afford the class fees. However, she may also not attend because she does not want the pregnancy. It is important to explore her reasons for non-attendance.

Negative Feelings About Pregnancy After 20 Weeks (CA, WA)

It is normal for a woman to experience some ambivalence regarding her pregnancy in the early weeks and it is helpful to discuss this with her and offer support. It is also important to determine a woman’s feelings later in the pregnancy, since an increased risk for child abuse is indicated by an unwanted and unaccepted pregnancy after 20 weeks. This may also be an indication of distress in her relationship with her partner, which may result in intimate partner violence. The woman may express unhappy feelings or demonstrate little interest in the pregnancy. In particular, it is important to determine a woman’s feelings about the pregnancy when she has initially decided to put the baby up for adoption and then changes her mind later in the pregnancy.

Relationship Problems with Parents (CA)

If a pregnant woman describes herself as having had a poor relationship with her parents when growing up, there is an increased likelihood of child abuse in the future. For example, a woman may describe herself as having had conflict and a lack of closeness with her mother, or she may have had feelings that her parents were displeased with her as a child. She may also have felt unaccepted by her family of origin, or describe the parenting she received as cold and rejecting. If opportunities arise, it would also be important to pursue the following lines of questioning with the woman’s partner as well.

Self-Esteem Issues(CA, WA)

Self-esteem can be defined as self-respect or having a favourable opinion of oneself. A woman with healthy self-esteem will feel good about herself, see herself as generally successful in life, and have secure and positive feelings about her mothering skills.Women who view themselves as unsuccessful in life often regard themselves negatively and have insecure feelings about their future mothering skills. These feelings of insecurity may be related to how they viewed their own mother’s feelings of competence and her ability as a parent. There is a good correlation between low maternal self-esteem and child abuse and a fair correlation with woman abuse.

Emotional/Psychiatric History(CA, WA, PD)

During the course of prenatal care, it is important to determine whether the woman has experienced a psychiatric disorder in the past or present because of the good association with postpartum child abuse and woman abuse, and fair association with postpartum depression.

Specifically, the conditions that have been found to be important include bipolar affective disorders, current psychosis, chronic psychiatric problems, chronic depression, or a history of past or present psychiatric treatment.

Depression in this Pregnancy (PD)

In general, 10-15% of new mothers experience a postpartum depression. However, recent studies indicate that about 10% of pregnant women are depressed. If a woman is clinically depressed during her pregnancy, she is at higher risk for a postpartum mood or anxiety disorder. In the postpartum period, if a woman presents with an acute onset of depression, discloses suicidal or infanticidal ideation or presents with manic behaviour, immediate referral to a psychiatrist is warranted for assessment and/or admission.

Other factors that increase her risk of experiencing postpartum depression include recent serious life stress, a lack of social support, couple relationship problems, a family history of depression, previous emotional and/or psychiatric problems, a previous postpartum depression, and a difficult infant.Acquainting the woman with community resources, e.g., PPD support groups or counselling services in the antenatal period, may be prudent. Discussing the signs and symptoms of postpartum mood and anxiety disorders during a visit with the woman and her partner would also be appropriate.

Alcohol Use in Pregnancy(WA, CA)

Abuse of alcohol or other substances by the woman or her partner is an important antenatal risk factor, both medically and psychosocially. Alcohol is a teratogen and infants may experience Fetal Alcohol Spectrum Disorder. Psychosocial risk factors include child abuse and woman abuse. Heavy use of alcohol may be determined from self-report, a history of black-outs, need for an “eye-opener”, loss of control, dependency on alcohol, and hallucinations or delirium tremens in the abstinence phase. The use of illicit drugs can be determined by urine assay or self-report. Abuse of sedative, hypnotic or prescription narcotics can be associated with significant postpartum difficulties.

Childhood Experience of Family Violence(CA, WA)

If a pregnant woman or her partner either experienced violence or witnessed violence during childhood, they are at higher risk for violence in their own family. Violent childhood experiences can include physical, emotional, and/or sexual abuse. There is a good correlation between the childhood experience of witnessing of abuse and child abuse, and a fair correlation with postpartum woman abuse.

Current of Past Woman Abuse(WA, CA, PD)

Woman abuse (intimate partner violence) and child abuse (endangerment) are under-reported by patients and under-diagnosed by health care providers. Studies have shown that pregnancy is a high-risk time for woman abuse.

If a pregnant woman has experienced or is currently experiencing abuse by her partner, she is at high risk of abuse during the rest of the pregnancy and during the postpartum period. There is also fair evidence that current or past woman abuse is associated with child abuse and postpartum depression. Woman abuse can be emotional, physical, sexual, financial, spiritual and social.

Previous Child Abuse by Woman or Partner (CA)

Child abuse or endangerment is the deliberate act of physically, sexually, or emotionally assaulting and/or violating a child’s rights or person. If either the pregnant woman or her partner has ever been officially reported to have committed any form of child abuse or if a child of theirs has ever been placed in foster care, there is a significant risk of abuse to the child the woman is carrying.

Once an antenatal factor associated with child abuse has been disclosed, the provider should further assess the significance and severity of the issue.  Important questions to be considered include: Are there currently children living in the home? Do the children appear to be at any risk for injury, neglect or abuse?  All health care providers and adults connected with the child and family, e.g., teachers, are bound by law to notify the appropriate child protective services in their area if they have suspicion that a child is being abused.

If a health care professional has any questions about a given situation, they can consult with children's aid society anonymously to get an opinion on that case. Contacting child protection services should not be delegated. Health care professionals are considered to have a greater burden of expectation regarding assessing for abuse, and have greater liability if they do not report.


If there is no child living in the home, but the provider is concerned about risk to the newborn, the women should be encouraged to contact her local child protection services agency to request aftercare support. Women who contact the local child protection services voluntarily feel more control and tend to view the agency as helpful rather than punitive.

Harsh Child Discipline (CA)

The use of corporal punishment, such as frequent and hard spanking or the use of physical punishment of a baby prior to crawling; excessive cursing at a child; withholding food, shelter, and basic requirements for healthy living; as well as deliberate emotional rejection are examples of harsh discipline and may be considered child abuse. There is a fine line between harsh child discipline and child abuse. Further questioning is warranted in order to have a clear a picture of the home environment as possible.

In addition, there are strong cultural components to child-raising and much behaviour observed at face value may be culturally appropriate to the family. Culture is not narrowly defined as ethnicity but relates to the family culture, e.g. the culture in the “Smith Family”, and the culture of a particular group, e.g., teen parents. It is important to ask parents not only about their parenting beliefs but also about the parenting beliefs of members of their extended families who may be involved in child rearing. Another question might be: Among your friends/family, how are children usually disciplined?


Once an antenatal factor of concern has been disclosed, a provider can collaborate with a pregnant woman around the decision-making to determine the best intervention for her life situation. A list of interventions is included at the end of the provider ALPHA Form and on the recap sheet for the self-report. For obstetricians and midwives, who do not have the mandate to deal with difficult family issues, referral back to the family physician is often appropriate. Family physicians and their office nurses, or staff, are often aware of the range of resources in their community. Community health nurses can also monitor the health of the mother/infant pair and the rest of the family through frequent home visits in the postpartum period.

The choice of intervention depends on several factors. First is its acceptability to the woman, e.g., in some cultures women would not go to a shelter if they are experiencing intimate partner violence. Also, the availability or lack of availability of a resource in the community, e.g., parenting courses for women who have experienced harsh parenting in their family of origin, will direct choices around interventions. One simple primary care intervention is scheduling more antenatal or postpartum visits, wherein the provider can offer continuous support and monitor the postpartum period for the development of problematic outcomes.


The ALPHA Forms have been developed as an evidenced-based, comprehensive and time-efficient way to interview around psychosocial issues in pregnancy. Both the provider-version and the self-report version yield comparable psychosocial data. Consequently, providers now have a choice of which tool to use with their antenatal patients, helping making antenatal assessment a part of their standard antenatal care.

Much of the information in this chapter is excerpted, with permission, from the ALPHA Provider’s Guide.


ALPHA Group: Family Physicians: Anne Biringer, June Carroll, Richard Glazier, Anthony Reid, Lynn Wilson; Psychiatrist, Donna Stewart; Anthropologist, Beverly Chalmers; Midwives, Maryn Tate, Freda Seddon; Nurse Educator/Researcher, Deana Midmer.

Carroll JC, Reid AJ, Biringer A, Midmer D, Wilson L, Permaul JA, Pugh P, Chalmers B, Seddon F, Stewart DE (2005). Effectiveness of the Antenatal Psychosocial Health Assessment (ALPHA) form in detecting psychosocial concerns: a randomized controlled trial. CMAJ. 173(3):253-9.

Carroll J, Reid A, Biringer A, Wilson L, Midmer D (1994). Psychosocial Risk Factors During Pregnancy: What do Family Physicians ask about? Canadian Family Physician, 40:1280-1290.

Midmer, D. Executive Producer (2003). Assessing Psychosocial Health in Pregnancy: Using The ALPHA Form, 2003. A Training Video for Providers. The Department of Family and Community Medicine, University of Toronto.

Midmer D,Biringer A, Carroll JC, Reid AJ, Wilson L, Stewart D, Tate M, Chalmers B (2003). A Reference Guide for Providers: The ALPHA Form - Antenatal Psychosocial Health Assessment Form. 3rd edition. Toronto: University of Toronto, Department of Family and Community Medicine.

Midmer D, Bryanton J, Brown R (2004). Assessing Antenatal Psychosocial Health Using Two Versions of the ALPHA Form. Canadian Family Physician. 50:80-87.

Midmer D, Carroll J, Bryanton J, Stewart D (2002).  From research to application: The development of an antenatal psychosocial health assessment tool.  CJPH. 93(4):291-6.

Reid A, Biringer A, Carroll J, Midmer D, Wilson L, Chalmers B, Stewart D (1998). Using the ALPHA Form in practice to assess antenatal psychosocial health. CMAJ. 159(6):677-684.

Wilson L, Reid A, Midmer D, Biringer A, Carroll J, Stewart D (1996). Antenatal psychosocial risk factors associated with adverse postpartum family outcomes. CMAJ. 15:785-791.

Section 2: Substance Use

Substance-using Pregnant Women

Author: Dr. Alice Ordean

Chapter Objectives

  • To review prevalence of substance use in pregnancy

  • To understand the range of consequences related to prenatal exposure to alcohol, tobacco and other drugs (ATOD)

  • To identify higher risk groups for ATOD use in pregnancy

  • To develop skills in screening women during pregnancy

  • To discuss how to advise women about ATOD use in pregnancy

  • To identify resources and services related to ATOD use and pregnancy


The prevalence of substance use in pregnancy is significantly underestimated in Canada. Rates of illicit drug use during pregnancy differ by locale and method of testing. Two Canadian national surveys collected exposure rates for pregnant and parenting women with children under age 5 to alcohol and tobacco (Statistics Canada, 1995a; Statistics Canada, 1995b). Alcohol use was found to be common during pregnancy with 17-25% of Canadian women reporting drinking at some point during the pregnancy. Whereas only 5% drank until becoming aware of the pregnancy, only 7-9% continued to drink throughout the entire pregnancy. Most women (>94%) reporting alcohol use during pregnancy consumed 1-2 drinks on drinking days and <3% reported 5 or more drinks per occasion. With respect to tobacco exposure, 16-23% of pregnant women in Ontario smoke with 52% smoking fewer than 10 cigarettes per day. Approximately one in five female smokers quit and another 50% cut down when planning to become pregnant or finding out about their pregnancy; however, the majority of pregnant women continue to use tobacco products despite potential adverse effects.

The demographics for alcohol use in pregnancy differ from other substance use. Women of increasing age who have higher education and income levels were more likely to report alcohol use in pregnancy than other socio-economic groups. This subgroup was also more likely to be moderate / daily drinkers and reported multiple substance use including smoking cigarettes and illicit drug use. Therefore, it is important to ask all women about substance use in pregnancy, regardless of their socio-economic status.

Rates of illicit drug use during pregnancy are difficult to ascertain. According to a survey from the British Columbia Centre of Excellence for Women’s Health, an estimated 5.5 to 6% of pregnancies involved significant substance abuse in the Vancouver Lower Mainland (BC Centre for Excellence in Women’s Health). A Toronto study used urine and hair screening of babies born in three nurseries and documented a prevalence of fetal exposure to cocaine during third trimester as 6.25% (Forman et al, 1994). Based on 80,000 births per year, this translates into 5,000 infants yearly in the Greater Toronto Area exposed to cocaine in utero. The Saskatoon Pregnancy and Health Study (SPHS) documented longitudinal alcohol, tobacco and illicit drug use during pregnancy (Muhajarine et al, 1997). Approximately 7% reported psychoactive drug use (usually marijuana), 46% reported drinking alcohol with the majority having fewer than 2 drinks per week and 33% reported smoking of which 52% smoked fewer than 10 cigarettes/day. These rates appear similar to those reported for illicit drug use by US studies. A range of results have been documented from as low as 2.8% to a high of ~15% depending on the geographic location of the study population (Ebrahim and Gfroerer, 2003; Jacob et al, 1995; Bibb et al, 1995; Chasnoff et al, 1990).

The most common reasons cited for first drug use include peer acceptance, problem solving, relief of pain, coping with feelings of lack of self-worth or inadequacy, curiosity, desire for recreation and influence of drug-using spouse (Fleming and Barry 1992, Hser et al, 1987; Best Start, 2002). First drug use usually consisted of marijuana or prescription drugs which then lead to other illicit drug use. Frequently women initiated substance use as a result of traumatic life events such as physical or sexual violence, sudden physical illness or disruption in family life. In addition, many women were raised in environments of heavy use of alcohol or drugs. Consistently, a male friend who was a daily user introduced women to drugs and the majority of women received drugs as a gift or from that friend (Hser et al, 1987). For women, relationships with a male friend or a male partner can mark the beginning of drug use and a cycle of addiction.

Pregnant substance users have unique psychosocial characteristics. Typically, these women tend to be younger (20s to early 30s), minority status, separated or divorced and tend to be unemployed, on social assistance or relying on partners or criminal activity for financial income (Fleming and Barry, 1992). High-risk groups in the general population for screening include those named above, as well as women with an unplanned and unwanted pregnancy, a history of previous child(ren) with developmental delays and a history of mood or anxiety disorders or eating disorders (Best Start, 2002).

General Approach to Care

Special Issues for Substance-using Pregnant Woman

Philosophy of care

  • Be respectful: create a non-judgmental, honest & open environment

  • Obtain consent for all procedures

  • Offer choices, explain alternatives, honour decisions

  • Provide woman-centred care: focus on woman’s needs, avoid being fetocentric

  • Employ harm reduction approach: reduce harm related to drug use – abstinence is not the only goal

  • Offer comprehensive care including addiction and prenatal care

  • Help them reconnect with health care & social systems

  • Advocate on behalf of pregnant substance user with child welfare authorities

Prenatal Issues

  • Offer prenatal care

  • Monitor for fetal growth and well-being

  • Deal with social issues such as housing, finances – connect with social worker or community agencies

  • Offer supervised urine drug screening to document abstinence

  • Encourage self-referral to child protection agency in third trimester

  • Develop a care plan for each patient outlining any special needs/situations

Intrapartum Issues

  • Provide adequate analgesia: opioid dependent women may require larger doses of analgesics à will not worsen addiction

  • Avoid a fetal scalp clip to prevent transmission of HepB/C & HIV

  • Plan iv access for injection drug users (recommended in case of emergency in women with poor iv access)  refer to anaesthesia for antenatal consult

Postpartum Issues

  • Plan disposition of baby prior to delivery with patient and social worker: rooming-in versus nursery depending on discharge plans and flight risk

  • Consider urine drug screen on baby using a bag sample

  • Offer Hepatitis A & B vaccines for Hepatitis C positive mothers

  • Weekly follow-up for baby and mom to assess coping skills, mood and neonatal growth and to monitor for relapse to drug use


Substance Abuse (DSM IV Criteria)

  1. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

    1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school or home

    2. Recurrent substance use in situations in which it is physically hazardous

    3. Recurrent substance-related legal problems

    4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

  2. The symptoms have never met the criteria for substance dependence for this class of substance.

Substance Dependence (DSM IV Criteria)

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

  1. Tolerance, as defined by either of the following:

    1. the need for markedly increased amounts of the substance to achieve intoxication or desired effect

    2. markedly diminished effect with continued use of the same substance amount

  2. Withdrawal, as manifested by either of the following:

    1. the characteristic withdrawal symptoms

    2. the same substance is taken to relieve or avoid withdrawal symptoms

  3. Substance is taken in larger amounts or over a longer period than intended

  4. Persistent desire or unsuccessful efforts to cut down or control substance use

  5. A great deal of time is spent on activities necessary to obtain, use or recover from effects of substance

  6. Important social, occupational or recreational activities given up or reduced due to substance use

  7. Substance use is continued despite knowledge of having persistent/recurrent physical or psychological problems likely caused or exacerbated by substance


American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Fourth edition, 1994.

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