Ir J Med Sci (2014) 183:231–240 DOI 10.1007/s11845-013-0996-9
ORIGINAL ARTICLE
Alcohol consumption in pregnancy: results from the general practice setting A. Nı´ Shu´illeabha´in • J. Barry • A. Kelly F. O’Kelly • C. Darker • T. O’Dowd
•
Received: 11 October 2012 / Accepted: 29 July 2013 / Published online: 10 August 2013 Ó Royal Academy of Medicine in Ireland 2013
Abstract Background There is no established safe level of alcohol consumption in pregnancy. Studies from Ireland have consistently shown lower abstention and higher binge drinking rates in pregnancy than other countries, indicating a high potential for foetal alcohol-related disorders. There has been little research on alcohol in pregnancy in primary care. Aims To determine the prevalence of alcohol consumption amongst pregnant women attending their GP for antenatal care, and to compare this to use in the year prior to conception. Methods Prospective cross-sectional study was carried out in fifteen teaching practices in the greater Dublin area. Women were recruited at their antenatal visits. Data were gathered by self-completed questionnaire in the practice, or researcher-administered telephone questionnaire. The questionnaire was based on the AUDIT, a WHO-validated data collection instrument designed for use in primary care. Results Two hundred and forty valid questionnaires were returned (80 % recruitment rate). Alcohol intake and binge drinking levels were much lower during pregnancy compared to the year prior to pregnancy (p \ 0.001). There was a marked reduction in the prevalence of alcohol use in pregnancy compared to previous research. Over 97 % drink no more than once a week, including almost twothirds of women who abstain totally from alcohol in pregnancy. Non-pregnant Irish women drink alcohol more
A. Nı´ Shu´illeabha´in (&) J. Barry A. Kelly F. O’Kelly C. Darker T. O’Dowd Department of Public Health and Primary Care, Trinity College Centre for Health Sciences, AMNCH, Tallaght, Dublin 24, Ireland e-mail:
[email protected]
frequently, and with higher rates of binge drinking, than women of other nationalities. Conclusions Primary care is a suitable setting to research alcohol use in pregnancy. Alcohol use in pregnancy in Ireland has decreased markedly compared to previous research from this jurisdiction. Keywords Alcohol drinking Family practice General practice Pregnancy Prevalence Primary care
Introduction There is no known safe level of alcohol consumption in pregnancy. Aside from the typical consequences of alcohol use for the mother, alcohol use in pregnancy also has the potential to harm the developing foetus. Fetal alcohol syndrome (FAS) is the most severe form of the wide range of diseases caused by prenatal alcohol exposure that are grouped under the umbrella term fetal alcohol spectrum disorders (FASD) [1, 2]. It is known that FAS is associated with chronic, daily alcohol consumption of six or more drinks per day, or with a monthly intake of at least 45 drinks, although not all women who drink this heavily will have a baby affected by FAS [3]. FASD include the more subtle foetal alcohol effects that are known to occur at lower (but as yet unquantified) levels of alcohol exposure. The incidence of FASD internationally has not been accurately determined [1, 2]. However, reported prevalence ranges from 0.06/1,000 live births in Australia [4] to 0.21–0.9/1,000 live births in the USA [5, 6]. International research shows very variable rates of alcohol use in pregnancy, from as low as 6 % [7, 8], to as high as 59 % [9]. Existing Irish data (from secondary care) indicate low abstinence rates in pregnancy. In a small study
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in 1992, Daly et al. [10] found that only 22 % of women abstained from alcohol in pregnancy. In 2008, Donnelly et al. [11] reported that 53.9 % of low-risk pregnant women interviewed admitted to drinking alcohol after a positive pregnancy test. Mullally et al. [12] reviewed data from 61,000 women who attended the Coombe Women’s Hospital for antenatal care between 2000 and 2007. They found that 81 % of women consumed alcohol periconceptionally (defined as pre-pregnancy up to confirmation of pregnancy). The Coombe Women’s Hospital Study included data from over 120,000 women attending for antenatal care over an 18-year period from 1987 to 2005 [13]. The researchers found that 28 % of women reported no alcohol use in pregnancy, 56 % reported up to 5 units per week, and 7.1 C 6 % units per week. Analysing the data by nationality showed that Irish women had the highest alcohol use in pregnancy, compared with women of other nationalities. Irish women were less likely to be abstinent (21 %), and 69 % drank up to 5 units per week. At the highest drinking level, 9.7 % of Irish women reported consumption of C6 units per week. This suggests a high potential for foetal alcohol-related disorders at a population level. To date, almost all research on this topic has been carried out in secondary care. Any research that has been conducted in primary care has focused on identification of women at risk of having an alcohol-exposed pregnancy [14–17], rather than the actual prevalence of alcohol use in pregnancy. General practice is the first point of contact with the healthcare system for the majority of pregnant women in Ireland [18]. The first hospital appointment is not generally until the second trimester. This is significant as alcohol use in the first trimester is often higher than at other stages of pregnancy (largely because many women do not realise they are pregnant) [19], yet this is the period when alcohol exposure poses the most risk to the foetus [3, 19]. The primary objectives of this study were to obtain data on the prevalence of alcohol consumption amongst pregnant women attending their GP for antenatal care, and to compare alcohol use at different stages of pregnancy, against use in the year prior to conception. A secondary objective was to examine the feasibility of collecting this type of data in general practice and to establish a methodology that could be replicated in future research.
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Fifteen GP practices were recruited. All were wellestablished practices involved in vocational training, with a mixture of urban, rural and suburban settings. Practices were divided randomly into three groups of five, and each practice was asked to recruit twenty patients (at any stage of pregnancy) over a 2-month period, aiming for three groups with 100 patients in each. Each of the three groups had a different methodology (see Table 1). All pregnant women over the age of 18 were eligible to participate. Sequential women were approached opportunistically at their antenatal visits and invited to participate, until the twenty patients for that practice were recruited (or until the recruitment period ended). Data were gathered by means of a self-completed questionnaire in March and April 2008. In the case of Group C, all questionnaires were administered over the telephone by the lead author. The questionnaire (see ‘‘Appendix’’) was based around the alcohol use disorders identification test (AUDIT)—a WHO-validated data collection instrument designed for use in primary care, to assure international comparability [20]. A total of 240 valid questionnaires were returned (i.e., 80 % of the target cohort were recruited). Data were analysed using SPSS and R [21, 22].
Analysis Paired responses to key questions regarding alcohol consumption during pregnancy, and in the 12 months prior to pregnancy are presented. Additional analysis allowed for the responses to be adjusted for relevant covariates such as age, trimester of pregnancy, and country of birth.
Table 1 Methodology for each group in the study Group
Methodology
A
The practices made a claim for each completed questionnaire they returned. The individual (GP or practice nurse) who recruited the patient and made the claim was the person who received the fee. The fee was €77, the same as the fee for completing a personal medical attendant (PMA) report at the time
B
A single bursary of €1,000 was paid to each practice for recruiting their twenty patients. The donation was made at the end of the study period, based on receipt of twenty completed questionnaires. A proportionately lower amount was paid if less than twenty patients were recruited
C
The practice staff (GPs or practice nurses) obtained the consent of the patient and a contact phone number. The consent forms and contact numbers were given to a researcher who then called the patient at home and administered the questionnaire over the telephone. The practice was paid a fee of €35 for each patient they recruited
Methods Routine antenatal care (ANC) in Ireland is shared between GPs and the maternity hospitals (combined ANC), and is provided free to all women. The majority of pregnant women (79.3 %) will attend their GP for at least some of their antenatal care [18].
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Results Data on prevalence of alcohol consumption obtained from the three groups were tested for differences, of which none were statistically significant. Therefore, these results are presented for the cohort as a whole. Prevalence of alcohol consumption Table 2 presents the cross-tabulation of paired responses to a question on frequency of alcohol use in pregnancy, compared to the 12 months prior to pregnancy. Women reported much lower frequency of alcohol use during pregnancy and this reduction was consistent across all trimesters of pregnancy (p \ 0.001). The rate of total abstention from alcohol in pregnancy was 62.4 %. Table 3 shows that when they did drink alcohol, pregnant women were significantly less likely to drink more than two units, compared to their intake when not pregnant. Table 4 compares levels of binge drinking while pregnant, to the year prior to pregnancy. Of the women who
reported binge drinking in pregnancy (8 % of the cohort), those who were interviewed by telephone frequently reported that this was a single episode before they realised they were pregnant. Binge drinking rates in the year prior to the current pregnancy were significantly higher than during the pregnancy (p \ 0.001). Irish women made up 77.7 % of the cohort, similar to national birth statistics [18]. The frequency of their alcohol use in pregnancy was not significantly different to women from other countries; however, all non-Irish women only ever drank 1–2 units at a time, compared to 83 % of Irish women. Table 5 shows the frequency of alcohol use by nationality in the year prior to the current pregnancy. In addition to drinking alcohol more frequently than women of other nationalities, Irish women had significantly higher rates of binge drinking in the year prior to pregnancy (p \ 0.001). Considering rates of alcohol use in pregnancy by age, younger women (18–24 years old) drank the least (both in terms of frequency, and number of units) compared to older
Table 2 Frequency of consumption of alcohol prior to pregnancy, compared to during pregnancy Prior to pregnancy
During pregnancy
%
Never
Monthly or less
2–4 times a month
2–3 times a week
4 ? times a week
Total
Never
33
0
0
0
0
33
13.9
Monthly or less
41
15
1
0
0
57
24.1
2–4 times a month
53
33
10
0
0
96
40.5
2–3 times a week
20
9
13
5
0
47
19.8
4 ? times a week
1
2
0
0
1
4
1.7
Total
148
59
24
5
1
237
%
62.4
24.9
10.1
2.1
0.4
Chi square test of independence = 126.7, df = 16, p \ 0.001 AUDIT question 1: how often do you have a drink containing alcohol?
Table 3 Paired responses in relation to the number of units of alcohol consumed during and prior to pregnancy Prior to pregnancy
During pregnancy
%
1 or 2 units
3 or 4 units
5 or 6 units
7 to 9 units
10 ? units
Total
1 or 2
16
0
0
0
0
16
18.4
3 or 4
30
0
0
0
0
30
34.5
5 or 6
22
3
1
0
0
26
29.9
7 to 9
5
3
2
0
0
10
11.5
10?
2
2
1
0
0
5
5.7
Total
75
8
4
0
0
87
%
86.2
9.2
4.6
0.0
0.0
Chi square test of independence = 27.9, df = 8, p \ 0.001 Women who had reported that they never drank alcohol, generally did not answer this question AUDIT question 2: how many units of alcohol do you drink on a typical day when you are drinking?
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Table 4 Paired responses on the extent of binge drinking (C 6 units on one occasion) during and prior to pregnancy Prior to pregnancy
During pregnancy
%
Never
Less than monthly
Monthly
Weekly
Total
Never
84
1
0
0
85
37.8
Less than monthly
69
4
0
0
73
32.4
Monthly
35
3
2
0
40
17.8
Weekly
19
6
0
2
27
12.0
Total
207
14
2
2
225
%
92.0
6.2
0.9
0.9
Chi square test of independence = 40.6, df = 9, p \ 0.001 AUDIT question 3: how often do you have six or more units of alcohol on one occasion?
Table 5 Frequency of alcohol use by nationality when not pregnant Ireland % (n)
Other EU Country % (n)
Rest of the world % (n)
Total % (n)
Never
6.1 (11)
25 (8)
60 (12)
13.4 (31)
Monthly or less
23.9 (43)
21.9 (7)
30 (6)
24.1 (56)
2–4 times a month
43.3 (78)
43.8 (14)
10 (2)
40.5 (94)
2–3 times a week
24.4 (44)
9.4 (3)
0
20.3 (47)
4 or more times a week
2.2 (4)
0
0
1.7 (4)
Total
100 (180)
100 (32)
100 (20)
100 (232)
N = 232 Table 6 Proportion of women in each trimester recruited to each group Group A (%)
Group B (%)
Group C (%)
Overall (%)
1st trimester
31.3
17.9
15.7
21.9
2nd trimester
31.3
31.0
27.1
30.0
3rd trimester
37.3
51.2
57.1
48.1
Total
100
100
100
100
women (25–34 years old, and C35-year-old age groups). Rates of binge drinking in pregnancy were uniformly low across all age groups. Prior to pregnancy, women in the 18–24-year-old age group still had the lowest frequency of alcohol use, but when they did take alcohol, they were much more likely to binge drink compared to older women, with 59 % drinking C5 units when they drank (including 25 % who drank C10 units at a time). This is similar to other Irish data [23]. Comparison of methodological groups The differing methodologies between the groups made no significant difference to recruitment of patients (n = 83 for Group A, n = 87 for Group B, n = 90 for Group C), or time taken to return questionnaires. Demographics were also comparable between the three groups, except that there was a higher proportion of Irish
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patients in Group C (91.4 %, versus 63.3 % in Group A, and 79.8 % in Group B). This may indicate that practices in this group tried to recruit women who spoke English as a first language, in anticipation of potential communication difficulties on the telephone. There were significant logistical difficulties with Group C. Of the 90 patients recruited, 22.2 % (n = 20) were not contactable at their phone number. For those that completed the questionnaire, it often took repeated attempts to contact them, and interviews frequently had to be conducted outside office hours. Women in Group C also tended to be further into their pregnancy when contacted (mean 27.5 weeks gestation, versus 22.3 for Group A and 24.7 for Group B; see Table 6), perhaps reflecting the time lag from recruitment to contact. Almost half the women were in their third trimester when surveyed, reflecting the fact that the frequency of GP visits increases as the pregnancy progresses.
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Discussion
Comparison with existing literature
Summary of main findings
One of the problems of comparison with international research is the different definitions of heavy/binge drinking used in different jurisdictions, and the fact that various researchers use either units of alcohol, or standard drinks, or the number of drinks taken. The definition of a standard drink also varies internationally. The British Medical Association (BMA) report on FASD has highlighted the difficulties of agreeing a definition even within the UK [1]. This study utilised the AUDIT questionnaire as it is specifically designed for use in primary care [20]. It records units of alcohol, and defines a binge as C 6 units. It should be a priority for researchers to agree on universal definitions of binge drinking, a standard drink, and heavy drinking. Many women find that they receive conflicting and confusing advice on how much alcohol is safe in pregnancy [29]—a point raised by several women in the telephone interviews. The WHO, the BMA and the Irish Health Service Executive (HSE) advise that pregnant women should not drink alcohol at all [1, 30, 31], particularly in the first trimester. However, many doctors, and the National Institute for Health and Clinical Excellence (NICE) advise that 1 or 2 units, on 1 or 2 days in the week, has not been proven to be harmful [32]. There has been considerable debate as to whether it is best to recommend total abstinence from alcohol in pregnancy, when there is no clear evidence that light drinking (1–2 units a week) is harmful [33–38]. However, other research suggests that even light drinking may cause subtle behavioural effects in children [39, 40]. All that is certain is that abstention eliminates the risk of FASD. Only one other paper was identified from the primary care literature looking at prevalence of alcohol use in pregnancy—this was a retrospective chart review conducted in a single practice with a narrow population base [41]. The current study appears to be the first reported prospective research on the prevalence of alcohol use in pregnancy, conducted exclusively in general practice.
Results show a marked reduction in the rates of alcohol use in pregnancy, particularly of Irish women, compared to previous research [10–13]. This suggests that women have become increasingly aware of the possible dangers of alcohol use in pregnancy, and adjust their behaviour accordingly. The vast majority (97.4 %) drink no more than once a week, including almost two-thirds of women who abstain totally from alcohol in pregnancy. Of the women who do drink alcohol in pregnancy, 86.4 % drink 1–2 units at a time. Non-pregnant Irish women continue to drink more heavily than women of other nationalities, and are significantly more likely to binge drink. The differing methodologies between groups made no difference to recruitment rates or results. There were significant logistical difficulties with conducting questionnaires by telephone interview that limit the value of this methodology. However, telephone interview has a useful role in obtaining qualitative data, or when working across large geographical areas [24]. Strengths and limitations of the study The strengths of this study include the high recruitment rate and the general practice setting, which allowed us to access women in the first trimester of pregnancy. Our sample is consistent with the general antenatal population when compared to national perinatal statistics. There are some limitations to the study. The questionnaire was not specific enough to ascertain whether an individual’s alcohol intake had changed over the course of their pregnancy, particularly regarding rates of binge drinking. There is also difficulty determining if women were honest about their alcohol use in pregnancy. There is evidence that self-reported alcohol use in non-pregnant populations can be reasonably reliable over time [25–28]. However, pregnant women may underreport alcohol use because they recognise that others may deem it unacceptable. Women were asked about their current alcohol use in pregnancy to minimise recall bias. The practices were not asked to record data regarding women who declined to take part in the study, but all were subsequently asked if any women had refused to participate, and it was reported as a rare occurrence. It may be that women with higher alcohol intakes would have avoided responding to any of the research methods.
Implications for clinical practice Women in this study have reduced alcohol usage promptly on finding out they were pregnant, indicating an awareness of the public health message regarding alcohol use in pregnancy. The time of greatest vulnerability to alcohol for the foetus is periconceptionally and in the first trimester, and it is around this issue that health promotion should focus—particularly as up to half of pregnancies are unplanned [1, 42, 43]. GPs are well placed to reinforce this message as they see women prenatally, and in their first trimester of pregnancy. Research shows that women are far more aware of the risks
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of smoking in pregnancy than those of continued alcohol use [10, 44]. It is essential that discussing safe alcohol use is a routine part of preconceptional counselling, and the first pregnancy consultation—this can be easily done by adding a prompt to the antenatal template of a practice’s software system. Proposed legislation on mandatory labelling of alcohol containers regarding the foetal risks of drinking needs to highlight the periconceptional period [45].
Conclusion
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The prevalence of alcohol use in pregnancy in Ireland has decreased markedly compared to previous research from this country, indicating successful health promotion in this regard. As alcohol use among non-pregnant Irish women remains higher than women from other nationalities, the focus of education should be around the need to reduce periconceptional alcohol intake. GPs have an important role to play in imparting this message. Acknowledgments Many thanks to the participating GP practices and their patients. Research funded by the Health Service Executive. Conflict of interest
This study examined the prevalence of alcohol use among pregnant women, and compared three methodologies for conducting such research in general practice. All three methods obtained comparable data on alcohol intake in pregnancy from participants, but there were significant logistical problems with administering the questionnaire by telephone interview.
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Ethical standard Practitioners.
None. Ethical approval from Irish College of General
Appendix: Research Questionnaire
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Practice ID No: _______
Questionnaire: Measurement of Alcohol Consumption in Pregnancy CONSENT:
Today’s Date:
____________
Would you mind answering some questions about your alcohol intake for a research study? Please tick the relevant box:
Yes
No
If you do mind, please do not complete the questionnaire, return it to reception. xxxxxxxxxxxxxxxxxx Demographic Data: Please tick the relevant box: Please indicate your age: 18-19
20-24
25-29
30-34
35-39
Over 40
What is your country of birth?
_________________________________
Do you have a medical card (GMS card)?
Yes
What is the due date for your baby?
_______________
How many weeks pregnant are you now?
__________ weeks
Do you have other children?
Yes
No
No
How many weeks pregnant were you when you found out you were expecting? __________ weeks Alcohol Intake: One unit of alcohol is: ½ pint average strength beer/lager one small glass of wine OR
OR
one single pub measure of spirits Note: a can of high strength beer or lager may contain 3 – 4 units. Please tick the relevant box: 1. In this pregnancy, how often do you have a drink containing alcohol? Never
Monthly or less
2-3 times a week
2-4 times a month
4 or more times a week
2. In this pregnancy, how many units of alcohol do you drink on a typical day when you are drinking? 1 or 2
3 or 4
7, 8 or 9
10 or more
5 or 6
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3. In this pregnancy, how often do you have six or more units of alcohol on one occasion? Never
Less than monthly
Weekly
Daily or almost daily
Monthly
FOR THE FOLLOWING QUESTIONS, PLEASE ANSWER BASED ON YOUR ALCOHOL INTAKE BEFORE YOU BECAME PREGNANT: 4. How often do you have a drink containing alcohol? Never
Monthly or less
2-3 times a week
2-4 times a month
4 or more times a week
5. How many units of alcohol do you drink on a typical day when you are drinking? 1 or 2
3 or 4
7, 8 or 9
10 or more
5 or 6
6. How often do you have six or more units of alcohol on one occasion? Never
Less than monthly
Weekly
Daily or almost daily
Monthly
7. How often during the last year have you found that you were not able to stop drinking once you had started? Never
Less than monthly
Weekly
Daily or almost daily
Monthly
8. How often during the last year have you failed to do what was normally expected from you because of drinking? Never
Less than monthly
Weekly
Daily or almost daily
Monthly
9. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never
Less than monthly
Weekly
Daily or almost daily
Monthly
10. How often during the last year have you had a feeling of guilt or remorse after drinking?
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Never
Less than monthly
Weekly
Daily or almost daily
Monthly
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239 11. How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never
Less than monthly
Weekly
Daily or almost daily
Monthly
12. Have you or someone else been injured as a result of your drinking? No
Yes, but not in the last year
Yes, during the last year
13. Has a relative or friend or doctor or another health worker been concerned about your drinking or suggested you cut down?
No
Yes, but not in the last year
Yes, during the last year
Thank you for taking the time to complete this study. The questionnaire is anonymous, and you cannot be identified from your answers. Please seal it in the envelope provided and remember to place it into the post-box at reception, or return it to the person who gave it to you. If you are worried about your alcohol intake, or have any questions raised by this study, please make an appointment to see your GP or the practice nurse. Yours Sincerely,
Dr. Aisling Ní Shúilleabháin (Researcher)
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