The European Journal of Public Health Advance Access originally published online on December 9, 2006
The European Journal of Public Health 2007 17(4):394-399; doi:10.1093/eurpub/ckl259
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Weekday but not weekend alcohol consumption before pregnancy influences alcohol cessation during pregnancy
Silvia Palma1, Rosa Pardo-Crespo2, Marcial Mariscal1, Rocío Perez-Iglesias2, Javier Llorca2 and Miguel Delgado-Rodríguez1,2
1 Division of Preventive Medicine and Public Health, University of Jaén Jaén, Spain
2 Division of Preventive Medicine and Public Health, University of Cantabria Santander, Spain
Correspondence: Prof. Dr M. Delgado-Rodríguez, Division of Preventive Medicine and Public Health, University of Jaén, Building B-323071-Jaén, Spain, tel: +34 953 212 703/+34 629 551 882, fax: +34 953 212728, e-mail: mdelgado{at}ujaen.es
Received May 18, 2006, accepted October 26, 2006
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Abstract |
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Background: Cantabria has the highest prevalence of alcohol consumption among women in Spain. Patterns of alcohol consumption before pregnancy were assessed as a determinant of alcohol cessation in pregnant women in Cantabria. Methods: Survey on a random sample of women delivering for the period 1998–2002 (n = 1510). Information was obtained from personal interview (data on alcohol consumption), clinical charts and prenatal care records. Relative risks (RR) and 95% confidence intervals (CI) were estimated. Multivariable analyses were carried out using logistic regression. Results: Nearly half (49.5%) of the women drank regularly before pregnancy and 22.7% during pregnancy. Sociodemographic variables favouring alcohol cessation were: high education level and smoking cessation, whereas high social class, advanced maternal age and employment outside of home decreased the rate of alcohol cessation. Cessation decreased with the amount of alcohol consumed on weekdays (P < 0.001), but not with intake during weekends only. In women with alcohol use only during weekends, only the consumption of spirits increased the rate of alcohol cessation (adjusted RR = 1.40, 95% CI: 1.13–1.60). Pre-pregnancy binge drinking (
4 drinks on one occasion) decreased alcohol cessation in pregnancy (adjusted RR = 0.66, 95% CI: 0.40–0.97). Conclusions: Drinking patterns influenced the rate of alcohol cessation: the heavier the alcohol consumption on weekdays, the lower the rate of alcohol cessation.
Keywords: alcohol cessation, alcohol consumption, pregnancy
According to the Spanish National Health Survey, the region of Cantabria has the highest frequency of alcohol consumption among Spanish women. More than 35% of Cantabrian women consume alcohol, which the Survey defines as having had at least one drink within the last week.1 This could suggest a high prevalence of alcohol consumption during pregnancy in Cantabria, although no data are available. Alcohol cessation in pregnancy is strongly recommended because of the adverse effects of alcohol on the newborn.2–4 Reduction of alcohol consumption in pregnant women has been reported in many countries,5,6, whereas in others, such as the US, no such change in drinking rates between 1987 and 1997 has been observed.7 Nevertheless, some women continue drinking during pregnancy, despite counselling on alcohol cessation in prenatal care. Assessment of alcohol intake patterns can contribute to an improvement in the efficacy of prenatal care programs on alcohol cessation.8 The main objective of this report is to analyse the influence of pre-pregnancy alcohol consumption patterns on the rate of alcohol cessation during pregnancy.
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Methods |
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The reference population came from Cantabria, a region in northern Spain with 530 000 inhabitants, 80% living in Santander (capital) or within a 25-km range. Most of the region's income comes from tourism. Pregnant women were selected from those delivering at the University Hospital Marques de Valdecilla between 1 April 1998 and 30 November 2002 and if they lived in Cantabria, the hospital's referral area. The hospital Ethics Committee authorised this observational study, and oral informed consent was sought from every eligible woman. During the study period, a random sample representing one-sixth of all women delivering at the hospital was drawn: all the women delivering on 5 days of each month, randomly selected in advance using the random number generator of a statistical program, were asked to participate. From among the women approached, 28 declined to participate, and 9 refused to answer the questions on alcohol drinking, yielding 1510 (97.6% of eligible) valid women for this report.
Data collection
The data were obtained from a personal interview (carried out within 3 days after delivery by four trained female medical residents), clinical charts and prenatal care records. The following information was obtained: mother's age at pregnancy, race, education level, marital status, socioeconomic class, occupation, obstetric history (parity, abortions from clinical chart), previous adverse perinatal outcomes, conditions during pregnancy (infections, hypertension, diabetes, and other obstetric conditions, from prenatal care record), prescribed and over-the-counter drugs, smoking, and prenatal care (number of visits, date of first visit) from both prenatal care record and interview. Social class was coded in five main levels [ranging from I (highest) to V (lowest)] according to the classification of the Spanish Society of Epidemiology,9 which is similar to the Black Report.10 Prenatal care utilisation was measured using the Kessner index.11 This classification of prenatal care takes into account the month prenatal care began, the number of prenatal visits, and the duration of pregnancy. It differentiates three levels of care: adequate, intermediate, and inadequate.
Alcohol consumption before and during pregnancy was assessed in the interview using a structured questionnaire in which the number of drinks and type of drink on weekdays, weekends (including Friday evening) and holidays (including the eve) were recorded. The questionnaire began with socially acceptable drinking habits (a glass of wine or beer at lunch (main meal in Spain) or supper on weekends or holidays) and ended with less acceptable habits (drinking without eating early in the morning during weekdays); these habits do not change with social class.1 During pregnancy, alcohol consumption can change and it is difficult to accurately recall drinking habits during different periods, so we asked for average consumption from the first trimester onward. The time frame for pre-pregnancy alcohol intake was a normal week with five working days. A woman was considered a ‘drinker’ if her intake was at least one alcoholic beverage a week. Binge alcohol drinking was defined as consumption of four or more drinks on one occasion in women with a daily alcohol consumption of less than two drinks. Other patterns of intake were not considered binge drinking.
Statistical analyses
Intensity of alcohol consumption was estimated in grams/day using standard volumes and alcohol degrees for alcoholic beverages consumed in Spain: beer (200 ml, 5°), wine (125 ml, 12°), and spirits (60 ml, 40°). The cut-offs for alcohol intake are based on a glass of wine containing 12 g of alcohol. The univariate relationship between different variables and alcohol cessation was tested using relative risk (RR) and its 95% confidence interval (CI); a RR >1 indicates that a variable favours alcohol cessation, whereas a RR <1 denotes that a variable favours alcohol continuation. Logistic regression analysis, yielding odds ratio (OR) as a measure of association, was used to adjust for potential confounders. OR figures approach RR ones if the frequency of outcome is low (i.e. <10%). Given that the frequency of alcohol cessation exceeded 40%, and in order to compare crude estimates with adjusted ones, adjusted ORs were transformed into RRs using the procedure described by Zang and Kai.12
To determine the variables to include in multivariate logistic regression analysis, the procedure established by Sun et al.13 was followed. We ran two stepwise models, one backward and another forward, allowing the entry of variables with P < 0.2.14,15 We made a list of predictors of alcohol cessation, identified in other studies.8,16,17 With the information of stepwise models and the list of predictors, a saturated model was built, and using a heuristic approach, variables that did not change the coefficient of alcohol drinking by >10% were discarded.14 The Stata 8/SE statistical package (College Station, TX, USA) was used for analysis.
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The characteristics of the study population were as follows. The average age was 29.6 (SD = 5) years, 37.4% were primiparous, 95.8% white (3.4% gipsy and 0.8% black), 91.1% married, and 49.7% were employed outside of home. The predominant education and social level was medium–low, 10.8% had university education, and 13.5% of women belonged to the two upper (I–II) social class levels. Frequency of smoking during pregnancy was 33.9%. Nearly half (49.5%) of the women drank before pregnancy and 22.6% during pregnancy (54.3% of drinkers stopped alcohol consumption during pregnancy).
The association between several characteristics of women and alcohol cessation is displayed in table 1. These analyses use the number of drinkers before pregnancy (n = 748) as the denominator. A high education level favoured alcohol cessation during pregnancy (adjusted RR = 1.43, 95% CI: 1.14–1.65). The same correlation was seen with these women quitting smoking (adjusted RR = 1.23, 95% CI: 1.00–1.44). On the contrary, high social class (adjusted RR = 0.72, 95% CI: 0.49–0.97) and employment outside of home (adjusted RR = 0.83, 95% CI: 0.70–0.97) decreased the rate of alcohol cessation. Both maternal age and partner's age showed significant inverse trends with cessation. Married women had higher rates of cessation than did non-married women, although it was not statistically significant (adjusted RR = 1.28, 95% CI: 0.96–1.57, P = 0.1). Prenatal care, number of previous pregnancies, previous adverse perinatal outcomes, and partner's smoking status were unrelated to alcohol cessation in multivariable analyses (results not shown).
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The relationships between pre-pregnancy drinking patterns and alcohol cessation during pregnancy are summarised in Table 2. The amount of alcohol consumed before pregnancy showed a highly significant negative trend (P < 0.001): consumption of
24 g/day clearly decreased alcohol cessation rates (adjusted RR = 0.31, 95% CI: 0.15–0.59). A pattern of drinking only spirits versus only beer favoured cessation (adjusted RR =1.39, 95% CI: 1.13–1.57). Pre-pregnancy binge drinking was shown by 42 (5.6%) and significantly decreased cessation rate (adjusted RR =0.66, 95% CI: 0.40–0.97).
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Patterns of pre-pregnancy weekday drinking related to alcohol cessation in pregnancy are displayed in table 3. The amount of alcohol intake during weekdays (table 3) showed a stronger relationship than did overall drinking (table 2): the RR estimates are lower for weekday drinkers than for overall consumption, being statistically significant for every amount of alcohol use. The RR estimates for type of drink were similar for beer, wine, and spirits, although significant figures were only obtained for daily wine consumers (higher sample size). Limited data for other beverages may preclude us from finding a significant difference.
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The results of weekends-only drinking are shown in table 4. No significant relationship was observed with the amount of weekend alcohol intake. Consumers of spirits only had higher rates of alcohol cessation than did beer drinkers (adjusted RR = 1.40, 95% CI: 1.13–1.60).
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To see whether reporting of alcohol cessation was influenced by delivery outcome, cessation rate was analysed according to several delivery outcomes. Of women who reported drinking during pregnancy, 21 (6.1%) had preterm deliveries, 11 (3.2%) had low birthweight newborns, 6 (1.8%) had babies with congenital malformations, and 14 had babies with an Apgar score at first minute of
6, whereas in women reporting alcohol cessation, these figures were 16 (3.9%), 10 (2.5%), 5 (1.2%), and 16, respectively. With the former adverse delivery outcomes, a composite variable (preterm or low birth weight or congenital malformation or low Apgar score versus none of the former) was built. Cessation rate was 48.2% (40/83) in women with adverse delivery outcomes and 55.0% (366/665) in the rest of women (crude RR = 0.88, 95% CI: 0.69–1.11, adjusted RR = 0.93, 95% CI: 0.71–1.14). |
Discussion |
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The frequency of alcohol consumption before pregnancy in this study was close to that reported in a rural area of Missouri (49.5 versus 48.6%).18 There were fewer light drinkers (<6 g/day) than in a study carried out in Minnesota (49.5 versus 53.7%),19 while the frequency of heavy drinkers (
24 g/day) (5%) was higher than in other studies.20,21 The most frequent type of beverage consumed by our women was wine, in accordance with Italian and British studies,17,22 while in other analyses carried out in Finland and California beer drinkers have been more prevalent.23,24 Pre-pregnancy binge drinking in our study (5.6%) is higher than in the US (2%)25 but lower than in low-income American latina women (10%).26 The percentage of alcohol intake during pregnancy (22.6%) in this study was higher than that found in other studies done in Finland (20%),23 Massachusetts (17%),27 and Pennsylvania (15%),28 but lower than the 40% found in 1989 in Valencia, the third metropolitan area of Spain,29 using similar definitions of drinking. The proportion of women who quit alcohol during pregnancy (54.3%) was similar to figures reported in Missouri (53.2%)18 but much lower than in a study carried out in Massachusetts (>80%).8
Among the sociodemographic characteristics related to alcohol cessation, two of the most important factors were high education levels and smoking cessation. These results agree with other studies carried out in Seattle, Minneapolis, and Boston.8,18,19 However, in a study done in Alaska, women with a high education were more reluctant to quit drinking,30 and no relationship was found in another Spanish study.29 High social class and employment outside of home were inversely correlated with alcohol cessation, in agreement with other reports.31,32 A woman's age during pregnancy showed a significant negative association with alcohol cessation: the higher the age, the lower the frequency of alcohol cessation. This has been also found in the UK33 and US.8,31
The overall amount of pre-pregnancy alcohol consumption showed a highly significant inverse relationship with alcohol cessation. Similar results have been obtained in women of London, Valencia, and California.17,29,34 When the type of beverage was analysed, wine consumption was associated with a lower rate of alcohol cessation. On the contrary, in an Australian study, beer drinkers were less likely to reduce their consumption during pregnancy than were drinkers of other beverages.16 Compared with beer drinkers, women in this study drinking only spirits on weekends had an increased frequency of alcohol cessation. This finding is indirectly supported by another report in which drinkers of only one type of beverage were more likely to reduce their alcohol intake.33 Nevertheless, drinking patterns are highly culturally determined, and the comparisons of local samples may be risky.
Our analysis for weekday drinkers showed a clear inverse relationship between the amount of weekday alcohol consumption and alcohol cessation, whereas this correlation was not observed in weekend-only drinkers. We have not found any previous reports differentiating alcohol consumption on weekdays and weekends/holidays. The fact that the relationship between alcohol cessation and amount of alcohol consumed before pregnancy only holds for weekday drinking may support the notion that the amount of routine (daily) alcohol consumption is a clear factor favouring alcohol consumption during pregnancy. In women drinking daily, the pattern of drinking only spirits was not observed. This pattern was noted in women drinking on weekends only. As mentioned before, these women had a higher rate of alcohol cessation; besides, they generally consumed low amounts of alcohol. We have not found any previous report relating pre-pregnancy binge drinking with alcohol cessation during pregnancy.
Our study may suffer from the limitation of gathering information after delivery. The influence of delivery outcome on alcohol reporting would have been avoided if alcohol intake was assessed during pregnancy. (This could have been done using prenatal care visits to get the data; however, obtaining a representative sample using this approach would be much more difficult in our region since 
15% of women have no prenatal care and another 15% use private prenatal care.) Could adverse effects in the newborns influence alcohol reporting? It has been shown that adverse effects in the newborns of our study population were uncommon, and there were no differences between women reporting cessation and those continuing to drink during pregnancy. This suggests that the influence of delivery on reporting alcohol drinking has been small.
Women responses on alcohol intake were not validated, so some degree of misclassification has to be assumed. It should be also noted that the frequency of alcohol drinking during pregnancy found in our sample is higher than in other populations; as exaggeration of alcohol intake is much less common that underreporting,35,36 this may imply that reasonably accurate responses to alcohol intake questions were obtained from our women.
Another limitation of our study is that we have not measured other variables that may be responsible for the differences between weekday and weekend alcohol consumption. More detailed assessment of daily alcohol consumption could help identify women who would continue drinking during pregnancy.
Our results emphasise that prevention of alcohol-related birth defects and developmental disorders requires early identification of at-risk women (fertile women planning conception who drink daily) prior to conception,37 as well as pregnant women who are currently consuming alcohol. Because women who are pregnant or may become pregnant are advised not to drink at all, it is recommended that all women of childbearing age in these and similar settings be asked about their alcohol use patterns and risk of pregnancy.38
It is important for clinicians to be aware of and acknowledge the difficulties female drinkers face and to develop motivation and skills to engage the women, their partners and support systems in their cessation attempts. The frequent contact women have with physicians during prenatal care may provide valuable opportunities to discuss alcohol use and to encourage and educate the women about needed health behaviour changes. In our population weekday drinking is associated with meals and this might be a pattern that is particularly difficult to change.
In summary, the drinking patterns influenced the rate of alcohol cessation: the more alcohol consumed on weekdays, the lower the rate of alcohol cessation, whereas moderate weekends-only consumption was unrelated to cessation frequency. Pre-pregnancy binge drinking also decreases alcohol cessation during pregnancy.
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Acknowledgments |
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This study was supported in part with funds from the Andalusian Regional Ministry of Research and Education (CTS 435) and from the Foundation Marques de Valdecilla (University of Cantabria).
Conflict of interest: None declared.
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