PSYC 103 HCC Effects of Maternal Alcohol Consumption During Pregnancy Analysis

Choose an article of interest from the list provided.

Create an analysis paper based on the research article

Students will analyze a peer-reviewed research article on a current topic in the field of Developmental Psychology with consideration to methodology, diversity, and ethics.

General Education Common Graded Assignment: PSYC 103 Fall 2022
Research Article Summary
PSYC 103: Principles of Human Growth and Development is a general education course designed to assist students in
the development of critical life skills. One of the goals of this course is to assess student competence for each of these
objectives:
I.
II.
III.
IV.
V.
VI.
Written and Oral Communication—Apply major human development theoretical perspectives with data
derived from research to maximize potentials and/or resolve developmental issues that typically occur in
each phase of life (CCO2)
Critical Analysis and Reasoning—Participate in analytical discussions of various topics found in human
development (CCO 9)
Information Literacy – Find, evaluate, use and cite academic resources pertaining to human development
topics (CCO4)
Scientific and Quantitative or Logical Reasoning – Evaluate the authenticity, timeliness, relevance, and
validity of information on human development found in print, online resources, film, television, radio and
other resources (CCO7)
Local and Global Diversity— analyze the similarities and differences of diverse multicultural, international,
and global perspectives in such areas as parenting styles, sexual expression, relationship patterns, treatment
of different age groups, gender roles, death, dying, bereavement, and other human development topics
(CCO 6)
Personal and Professional Ethics—Identify the advantages and disadvantages of the various research
methods, including the ethical considerations, used to study human development throughout the lifespan
(CCO3).
ASSIGNMENT:
Students will choose one of the research articles from the attached approved list and locate the article and supporting
research in a CCBC Library database. Students will create an academic analysis of the article.
Purpose: For students to evaluate a peer-reviewed research article on a current topic in the field of Developmental
Psychology with consideration to methodology, diversity, and ethics.
Audience: Educated adults with some understanding of research methodology.
Directions:
Choose an article of interest from the list provided. Locate this article in the CCBC library database.
Create an analysis paper based on the research article according to the specific instructions attached.
Students will analyze a peer-reviewed research article on a current topic in the field of Developmental Psychology with
consideration to methodology, diversity, and ethics. The student will select an article of interest from the approved list
and write a minimum 12-paragraph article summary using specified section headings and including content as directed.
ASSIGNMENT SPECIFICATIONS:
• Minimum 12 well-written paragraphs, typed in Times New Roman 12-pt font, double spaced, with 1” margins.
The References page is not included in the assigned page length.
• APA 7 student style format and documentation for parenthetical citations and a References page.
• Students should cite their chosen article and any additional sources used (e.g., textbook, other research
articles), both using parenthetical citations throughout the paper and in a References page.
• Use library resources to locate appropriate resources including:
CCBC Library Citation Basics APA 7 Research Guide
CCBC Library Psychology: Human Development Research Guide
GRADING:
• This assignment will account for at least 10% of the total course grade.
• See attached rubric for details about how the research analysis will be graded.
SUBMISSION GUIDELINES:
• Student work must be collected in the last third of the semester and before Finals Week.
• Electronic submissions must be made with the student’s ID number (900 or 901#) as the file name through
Brightspace. Student and instructor names should not appear on electronic submissions.
PSYC 103: Principles of Human Growth and Development
Research Article Summary
Step 1: Choose an article
•
•
Choose one (1) of the research articles from the list provided below.
After you have made a selection, locate the article using the CCBC Library Database (read the entire article
thoroughly, and take notes).
You will need your student ID and password to access the CCBC database.
To support your success in completing this paper, please complete at least one (1) of these activities.
•
•
•
Participate in a Research Assistance Program (RAP) appointment with a CCBC librarian.
For more information and to schedule your appointment, click here.
(Please ask the librarian to provide documentation to submit to your professor.)
Complete the LibraryLEARN online video course.
(Please be sure to enter your full name, e-mail address, course – PSYC 103, and instructor’s name when you
begin the pretest.)
Participate in the Writing and Literacy Center’s free writing assistance process.
For more information and to submit your request for assistance, click here.
(Please submit the feedback you receive to your professor.)
Step 2: Begin Writing Your Paper
Create an article summary that includes each of the following sections.
1.
2.
3.
4.
5.
6.
7.
•
•
Cover Page with Title (Use the title of the article you selected)
Thesis/Research Question
Rationale
Methods
Results/Conclusions
Analysis
Critical Thinking
Use APA 7 style headings, page format, and references (in-text and in the References page).
The instructions for each section include a recommended number of paragraphs; however, depending on the
article you choose, you may need additional paragraphs to thoroughly address your topic.
1. Cover Page with Title
Include the name of the article you selected and your student ID number. Do NOT put your name on the
document.
2. Thesis/Research Question (What do the researchers want to know?)
Using information in the Abstract and introductory section of the research article:
o identify the thesis or question the researcher(s) wanted to investigate,
o provide a general background of the topic being investigated, and
o define/explain any terms used by the researcher(s) that are critical to one’s understanding of the topic or study.
Expected length: Approximately one well-developed paragraph
3. Rationale (Why are the researchers conducting this investigation?)
What prior research outcomes or lack of previous research led the researcher(s) to conduct the study you have
selected?
For example, if researcher(s) are doing a study about a new medication to be given to children, then part of the
rationale (i.e., reason) might be that no one has researched this medication on children before.
Another possibility could be that the medications currently in use have serious side effects for many children.
Cite at least one source the researcher(s) used in the article as justification for their investigation.
o Use APA formatting in your text and in the reference list.
Expected length: Approximately one well-developed paragraph
4. Methods (Who participated, what happened, and how did the researchers collect data?)
•
Participants/Subjects:
Describe who participated in this study (the participants/subjects) and the process of how they were selected to
participate.
• Procedures/Methods:
Describe the procedures, or what was required of the participants/subjects during the active phase of the study
and what information was collected.
• Measurement Tools:
Describe any measurement instruments used to collect data in the study (i.e., interviews, surveys, video,
checklists, journals, photographs, observations, etc.).
Expected length: Approximately two to three well-developed paragraphs
5. Results/Conclusion (What were the outcomes of the study, and what did the researchers conclude?)
•
•
•
What were the reported primary outcomes of this study?
What, if any, were the secondary or unexpected outcomes reported by the researcher(s)?
What conclusion did the researcher(s) make based on the data they collected from the participants?
o Do not report or try to interpret numerical/statistical outcomes from the charts or text of your article.
o Focus on and summarize the written section of your selected article that is titled “Results,” “Findings,”
or “Conclusion/Discussion.”
Expected length: Approximately one to two well-developed paragraphs
6. Analysis (How do the outcomes of the study contribute to existing knowledge, and what are the implications
for the real world?)
Using the information, you reported in your Results/Conclusion section above, in your own words discuss
how you believe the outcomes of this study can be applied to real-world situations. This section of your
paper is your analysis and opinion, and you may use first person (I, me, etc.)
• Choose one of the outcomes and discuss the possible real-world applications in your own words.
o For example: Suppose the outcome of the study is that children who receive quality early
childhood education enter kindergarten with better verbal skills than children who do not
attend this kind of program. You infer that the real-world application of this outcome would be
to provide free, universal, high-quality early childhood education programs to all children to
increase their verbal skills and ensure that they are ready to start kindergarten and succeed.
How do the outcomes of this study contribute to science or the existing knowledge?
You will need to consult your textbook and/or additional outside sources to address this point.
• How do the outcomes of this research integrate or expand with the content you have learned in Human
Growth and Development?
You will need to consult your textbook and/or additional outside sources to address this point.
• Consider the participants used for this study. In what ways do the selected participants limit the ability
to generalize the study’s results to people from diverse backgrounds (i.e., other than the one(s) studied
in this research study)? If the researchers replicated the study but used different participants, what
elements of diversity would you choose to include and why?
o
For example: The researchers found that children who receive quality early childhood education
enter kindergarten with better verbal skills than children who do not attend this kind of program
included participants from families with high socioeconomic status.
How might the outcomes be different if the researchers conducted the same study with families
from low socioeconomic status backgrounds?
NOTE: Diversity can include age/ageism, gender/gender identity, sex/sexual orientation, race, ethnicity, religion,
socioeconomic status, education level, family status or structure, geographic location, cultural beliefs or
practices, people with a disability, biological differences, and unique genetic markers
Expected length: Approximately two to three well-developed paragraphs
7. Critical Thinking (How did the researchers take into consideration ethical principles while conducting and
reporting their research?)
In this section, you will identify the steps the researchers took (or did not take) to ensure that the study was
done in accordance with ethical guidelines.
To familiarize yourself with ethical expectations in social sciences research, please watch this video.
•
•
•
Based on your understanding of research ethics, discuss whether or not the researchers conducted the
study in an ethical manner.
Support your opinion by referencing specific examples from the study that indicate the use of (or failure to
use) ethical research practices.
Some examples may include approval by an institutional review board and confidentiality.
Expected length: Approximately one well-developed paragraph
Before you submit your Analysis:
1. Review the following Check List to ensure you have met the assignment requirements.
 Your analysis includes at least 12 paragraphs identifying each of the research elements noted above.
 You have followed APA 7 rules for quotations, paraphrases, and citations/references.
 You have used quotations for less than 20% of your paper; at least 80% of your paper is in your own words.
 Proofread/edit your paper prior to submission; check for correct spelling, capitalization and grammar.
 Your submission includes a References page with the research article and any other sources cited in APA
format, as part of the document.
2. Name your document file with your student ID number only. NOWHERE in your paper should you include your name
or your instructor’s name. Please be sure to include only your Student ID number.
3. Upload your paper to Brightspace, per your instructor’s instructions, by the identified due date.
Human Development Research Articles
Prenatal Development
Addila, A. E., Azale, T., Gete, Y. K., & Yitayal, M. (2021). The effects of maternal alcohol consumption during pregnancy
on adverse fetal outcomes among pregnant women attending antenatal care at public health facilities in Gondar town,
Northwest Ethiopia: a prospective cohort study. Substance Abuse Treatment, Prevention & Policy, 16(1), 1–15.
https://doi-org.ccbcmd.idm.oclc.org/10.1186/s13011-021-00401-x
Vitt, N., Vecchi, M., James, J., & Belot, M. (2022). Maternal stress during pregnancy and children’s diet: Evidence from a
population of low socioeconomic status. Nutrition, 93. https://doi-org.ccbcmd.idm.oclc.org/10.1016/j.nut.2021.111423
Infancy
Duh-Leong, C., Messito, M. J., Katzow, M. W., Tomopoulos, S., Nagpal, N., Fierman, A. H., & Gross, R. S. (2020). Material
Hardships and Infant and Toddler Sleep Duration in Low-Income Hispanic Families. Academic Pediatrics, 20(8), 1184–
1191. https://doi-org.ccbcmd.idm.oclc.org/10.1016/j.acap.2020.07.003
Charlotte Webber, Jacqueline Blissett, Elsa Addessi, Amy T. Galloway, Laura Shapiro, & Claire Farrow. (2021). An infant‐
led approach to complementary feeding is positively associated with language development. Maternal and Child
Nutrition, 17(4). https://doi-org.ccbcmd.idm.oclc.org/10.1111/mcn.13206
Early Childhood
Coyne, S. M., Rogers, A., Shawcroft, J., & Hurst, J. L. (2021). Dressing up with Disney and Make-Believe with Marvel: The
Impact of Gendered Costumes on Gender Typing, Prosocial Behavior, and Perseverance during Early Childhood. Sex
Roles, 85(5/6), 301–312. https://doi-org.ccbcmd.idm.oclc.org/10.1007/s11199-020-01217-y
Razza, R. A., Linsner, R. U., Bergen-Cico Dessa, Carlson, E., & Staceyann, R. (2020). The feasibility and effectiveness of
mindful yoga for preschoolers exposed to high levels of trauma. Journal of Child and Family Studies, 29(1), 82-93.
http://dx.doi.org/10.1007/s10826-019-01582-7
Skočajić, M.,M., Radosavljević, J.,G., Okičić, M.,G., Janković, I.,O., & Žeželj, I.,L. (2020). Boys just don’t! Gender
stereotyping and sanctioning of counter-stereotypical behavior in preschoolers. Sex Roles, 82(3-4), 163-172.
http://dx.doi.org/10.1007/s11199-019-01051-x
Middle Childhood
Perrier, R., Bernier, A., Dirks, M., Daspe, M.-È., & Larose-Grégoire, É. (2020). Longitudinal Linkages Between Coparenting
and Subsequent Friendship Quality in Middle Childhood. Journal of Child & Family Studies, 29(11), 3091–3102.
https://doi-org.ccbcmd.idm.oclc.org/10.1007/s10826-020-01821-2
Mewhort-Buist, T., Nilsen, E. S., & Bowman-Smith, C. (2020). Children’s Communicative Decisions Are Influenced by
Gender, Shyness, and Peer Experiences. Merrill – Palmer Quarterly, 66(1), 1-33.
http://ccbcmd.idm.oclc.org/login?url=https://www.proquest.com/scholarly-journals/childrens-communicativedecisions-are-influenced/docview/2462153726/se-2?accountid=3784
Adolescence
Isaksson, J., Westermark, C., Koposov, R. A., Stickley, A., & Ruchkin, V. (2021). Risky sexual behaviour among Russian
adolescents: association with internalizing and externalizing symptoms. Child and Adolescent Psychiatry and Mental
Health, 15, 1-9. http://dx.doi.org/10.1186/s13034-021-00393-3
Thorisdottir, I. E., Sigurvinsdottir, R., Kristjansson, A. L., Allegrante, J. P., Lilly, C. L., & Sigfusdottir, I. D. (2020).
Longitudinal association between social media use and psychological distress among adolescents. Preventive
Medicine, 141. https://doi-org.ccbcmd.idm.oclc.org/10.1016/j.ypmed.2020.106270
Young Adulthood
McAllister, P., Henderson, E., Maddock, M., Krista, D., Fincham, F. D., & Braithwaite, S. R. (2020). Sanctification and
cheating among emerging adults. Archives of Sexual Behavior, 49(4), 1177-1188. http://dx.doi.org/10.1007/s10508-02001657-3
Olenik-Shemesh, D., Heiman, T., & Keshet, N. S. (2018). The Role of Career Aspiration, Self-Esteem, Body Esteem, and
Gender in Predicting Sense of Well-being Among Emerging Adults. Journal of Genetic Psychology, 179(6), 343–356.
https://doi-org.ccbcmd.idm.oclc.org/10.1080/00221325.2018.1526163
Middle Adulthood
Infurna, F. J., Staben, O. E., Lachman, M. E., & Gerstorf, D. (2021). Historical change in midlife health, well-being, and
despair: Cross-cultural and socioeconomic comparisons. American Psychologist, 76(6), 870–887. https://doiorg.ccbcmd.idm.oclc.org/10.1037/amp0000817.supp
(Supplemental)
Dixon, J. S., Coyne, A. E., Duff, K., & Ready, R. E. (2021). Predictors of cognitive decline in a multi-racial sample of midlife
women: A longitudinal study. Neuropsychology, 35(5), 514–528. https://doiorg.ccbcmd.idm.oclc.org/10.1037/neu0000743.supp
(Supplemental)
Weiss, D., & Kunzmann, U. (2020). Longitudinal changes in subjective social status are linked to changes in positive and
negative affect in midlife, but not in later adulthood. Psychology and Aging, 35(7), 937–947. https://doiorg.ccbcmd.idm.oclc.org/10.1037/pag0000572.supp
(Supplemental)
Late Adulthood
Perone, A. K., Ingersoll-Dayton, B., & Watkins-Dukhie, K. (2020). Social Isolation Loneliness Among LGBT Older Adults:
Lessons Learned from a Pilot Friendly Caller Program. Clinical Social Work Journal, 48(1), 126–139. https://doiorg.ccbcmd.idm.oclc.org/10.1007/s10615-019-00738-8
Kahana, E., Kahana, B., Bhatta, T., Langendoerfer, K. B., Lee, J. E., & Lekhak, N. (2020). Racial differences in future care
planning in late life. Ethnicity & Health, 25(4), 625–637. https://doiorg.ccbcmd.idm.oclc.org/10.1080/13557858.2019.1573974
Thoma, M. V., Kleineidam, L., Forstmeier, S., Maercker, A., Weyerer, S., Eisele, M., van den Bussche, H., König, H.-H.,
Röhr, S., Stein, J., Wiese, B., Pentzek, M., Bickel, H., Maier, W., Scherer, M., Riedel-Heller, S. G., & Wagner, M. (2021).
Associations and correlates of general versus specific successful ageing components. European Journal of Ageing, 18(4),
549–563. https://doi-org.ccbcmd.idm.oclc.org/10.1007/s10433-020-00593-4
Addila et al. Substance Abuse Treatment, Prevention, and Policy
https://doi.org/10.1186/s13011-021-00401-x
(2021) 16:64
RESEARCH
Open Access
The effects of maternal alcohol
consumption during pregnancy on adverse
fetal outcomes among pregnant women
attending antenatal care at public health
facilities in Gondar town, Northwest
Ethiopia: a prospective cohort study
Alemu Earsido Addila1,2* , Telake Azale3, Yigzaw Kebede Gete2 and Mezgebu Yitayal4
Abstract
Background: The teratogenic effect of fetal alcohol exposure may lead to actual and potential problems, instantly
after birth, at infancy; or even later, and mental impairment in life. This study aimed to investigate the effects of
maternal alcohol consumption during pregnancy on adverse fetal outcomes at Gondar town public health facilities,
Northwest Ethiopia.
Methods: A facility-based prospective cohort study was performed among 1778 pregnant women who were
booked for antenatal care in selected public health facilities from 29 October 2019 to 7 May 2020 in Gondar town.
We used a two-stage random sampling technique to recruit and include participants in the cohort. Data were
collected using the Alcohol Use Disorders Identification Test – Consumption (AUDIT-C) standardized and pre-tested
questionnaire. Multivariable analysis was performed to examine the association between reported prenatal alcohol
exposure (non-hazardous and hazardous) and interested adverse birth outcomes using log-binomial regression
modeling. The burden of outcomes was reported using the adjusted risk ratio and population-attributable risk
(PAR).
* Correspondence: alexisersid@gmail.com
1
Department of Public Health, College of Medicine and Health Sciences,
Wachemo University, Hossana, Ethiopia
2
Department of Epidemiology and Biostatistics, College of Medicine and
Health Sciences, Institute of Public Health, University of Gondar, Gondar,
Ethiopia
Full list of author information is available at the end of the article
© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article’s Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
Addila et al. Substance Abuse Treatment, Prevention, and Policy
(2021) 16:64
Page 2 of 15
Results: A total of 1686 pregnant women were included in the analysis, which revealed that the incidences of low
birth weight, preterm, and stillbirth were 12.63% (95% CI: 11.12, 14.31), 6.05% (95% CI: 5.00, 7.29) and 4.27% (95% CI:
3.4, 5.35), respectively. Non-hazardous and hazardous alcohol consumption during pregnancy was significantly
associated with low birth weight (ARR = 1.50; 95% CI: 1.31, 1.98) and (ARR = 2.34; 95% CI: 1.66, 3.30), respectively.
Hazardous alcohol consumption during pregnancy was also significantly associated with preterm birth (ARR = 2.06;
95% CI: 1.21, 3.52). The adjusted PAR of low birth weight related to non-hazardous and hazardous alcohol drinking
during pregnancy was 11.72 and 8.44%, respectively. The adjusted PAR of hazardous alcohol consumption was
6.80% for preterm.
Conclusions: Our findings suggest that there is an increasing risk of adverse birth outcomes, particularly preterm
delivery and low birth weight, with increasing levels of alcohol intake. This result showed that the prevention of
maternal alcohol use during pregnancy has the potential to reduce low birth weight and preterm birth. Hence,
screening women for alcohol use during antenatal care visits and providing advice with rigorous follow-up of
women who used alcohol may save the fetus from the potential risks of adverse birth outcomes.
Keywords: Pregnant women, Alcohol use, Adverse health outcomes, Ethiopia
Background
Alcohol consumption during pregnancy may have adverse effects not only on the incidence of diseases, injuries, and other health conditions to the women but also
on the infants and children [1]. Pregnant women may
consume alcohol without fully understanding the ill effects of alcohol consuming [2]. Since alcohol passes
through the placental, fetal blood may have the same
blood alcohol concentration or higher than that of the
mother that can result in various adverse effects on the
fetus besides the risk of harm to the mother [3]. The
body of the fetus during the developmental stage does
not similarly process alcohol an adult does; the alcohol
is more concentrated in the body of the fetus, and it can
prevent the passage of adequate amount of nutrition and
oxygen to the vital organs of the fetus [4]. Subsequently,
the teratogenic effects of fetal alcohol exposure may lead
to actual and potential problems, instantly after birth, at
infancy, or even later, leading to anatomical abnormalities, behavioral problems, and mental impairment in life
[5]. On the other hand, a wide range of birth defects
termed fetal alcohol spectrum disorder (FASD) has been
associated with alcohol use during pregnancy [6–8].
The degree of effects of alcohol use during pregnancy
may vary depending on the frequency of exposure to alcohol, dose, duration, genetic factors, maternal nutrition,
and developmental stage of the fetus at exposure [3, 9–
12]. Due to genetic and lifestyle factors, there may also
have different outcomes from the same exposure [13,
14]. However, there is no currently assured exact doseresponse relationship between the amount of alcohol
consumed during the pregnancy and the degree of the
problem or a risk threshold caused by alcohol in the infant [15]. According to different studies, nobody knows
the exact amount of alcohol that is potentially harmful
to the developing baby in any trimester. Hence,
researchers and health professionals recommend not
drinking any amount of alcohol for pregnant women as
well as women who are trying to get pregnant [16–23].
The consequences and safety of low-to-moderate alcohol
consumption during pregnancy on the fetus is still inconclusive and discordant [9, 15, 24, 25].It is argued that
the lack of agreement between studies might be due to
heterogeneity of the study participants, methodological
differences, low statistical power, potential confounding
factors, and the difference in detecting tools used or
biased information on maternal alcohol consumption
[23, 26]. On the other hand, multiple adverse birth outcomes have been correlated with hazardous alcohol use
during pregnancy, including low birth weight, preterm
birth, intrauterine growth retardation (IUGR), having
low weight for head circumferences, and small for gestational age (SGA) [9, 25, 27].
Despite many guidelines that advise that women
should avoid drinking any alcoholic beverages during
any stage of pregnancy to save future generations from
alcohol-associated mental, physical, and behavioral abnormalities, numerous studies have shown that a significant number of pregnant women continue to drink
alcohol in Ethiopia [28–31]. Regardless of a high proportion of pregnant women consume alcoholic beverages;
policies have paid little attention to risks associated with
alcohol consumption during pregnancy.
In Ethiopia, due to the rapid expansion of industriallymanufactured newly branded alcoholic beverages over
time and the rising purchasing power of the society [32],
a great proportion of pregnant mothers consume alcoholic beverages [28–31]. Moreover, homemade indigenous alcoholic beverages such as Tella (traditional
Ethiopian beer fermented from mostly barley but also
with wheat, maize, sorghum, and mixed with ‘Gesho’
[Rhamnusprinioides]) [33], Areki (a whiskey-like drink
Addila et al. Substance Abuse Treatment, Prevention, and Policy
(2021) 16:64
distilled from fermented barley or maize and mixed with
[Rhamnusprinioides]), and Tej (a honey wine), Borde,
and Korofe are generally common in Ethiopia and everyone drinks without any confinement of official body
[34].
Previously conducted studies in different parts of the
world had an inconsistent association between prenatal
alcohol exposure and adverse fetal outcomes to take appropriate interventions [9, 35–39]. Therefore, this study
focused on determining the effects of alcohol use during
pregnancy on adverse fetal outcomes such as preterm,
stillbirth, and low birth weight, as they are one of the
major causes of neonatal morbidity and mortality in
low- and middle-income countries [40], including
Ethiopia [41–43]. By investigating the effects of alcohol
consumption during pregnancy, the present study could
make a novel share to help fill the gaps in the current
literature and update future guidelines concerning alcohol consumption during pregnancy.
Materials and methods
Study design, period, and study setting
We carried out a facility-based prospective cohort study
among pregnant women who were booked for antenatal
care in selected public health facilities from 29 October
2019 to 7 May 2020 in Gondar town. The included
health facilities were one hospital (University of Gondar
Comprehensive Specialized Hospital) and three health
centers (Gondar polyclinic, Azezo, and Maraki). Gondar
town is located about 727 km far from Addis Ababa, the
capital city of Ethiopia. According to the Gondar town
Finance and Economic Development branch Office report in 2018, the total population of Gondar town was
approximately 338, 646 (165, 937 males and 172, 709 females). Of these females, 7454 were estimated to be
pregnant. In the town, there are eight health centers and
one comprehensive specialized hospital [44].
Sample size determination and sampling procedure
The sample size was determined by using EPI INFO version 7.2.1.0 STAT CALC software cohort study as described by Fleiss with continuity correction to estimate
the sample size (https://silo.tips/download/statcalccalculating-a-sample-size-with-epi-info) [45]. We used
the following assumptions: two-sided 95% confidence
level, power of 80%, the ratio of sample size 2:1 to detect
the odds ratio of 1.9 by considering 6.4% of low birth
weight in the unexposed group and 11.7% in the exposed
group to bring a difference in two population based on
the research conducted in Brazil [46]. These rates were
taken from a study conducted in another country because we did not find similar studies in Ethiopia or other
similar situations. Finally, 1778 study participants (593
exposed and 1185 unexposed to alcohol use) were
Page 3 of 15
enrolled using a design effect of 1.5 and 10% withdrawn
or attrition rate from the cohort for a variety of reasons.
We used a two-stage random sampling technique to recruit pregnant women and include them in the cohort.
In the first stage, we applied simple random sampling to
select three health centers. In addition to these three
health centers, one hospital was purposively included in
the study. In the second stage, pregnant mothers who
fulfilled the inclusion criteria were chosen using a systematic sampling technique. The sample size was proportionally allocated to each health facility based on
previous client-flow information. A flow diagram of the
study participants was presented in (Fig. 1).
Study variables
The outcome of interest
Information on birth outcomes was obtained from
health facilities’ maternity records and interviewing the
mothers. The outcome interest variables of the study
were preterm, stillbirth, and low birth weight which were
categorized as a dichotomous variable (yes/no); we used
the World Health Organization (WHO) recommended
definition for international comparisons for the outcomes. Birth weight was obtained from the delivery logbook to categorize infants as low birth weight (< 2500 g) regardless of gestational age. The estimated time of conception and subsequent gestational age at delivery was calculated based on the first day of the last menstrual period (LMP) or an ultrasound estimated result. Preterm delivery and stillbirth were defined as babies born before 37 weeks of pregnancy and a baby born with no signs of life at or after 28 weeks of gestation, respectively. Alcohol consumption during pregnancy was the main independent variable. Potential confounding variables Data were collected at baseline and postnatal on various risk factors through the pregnancy, including comprehensive maternal characteristics and potential confounding variables. Besides, detailed pregnancy history was gathered, including pre-existing medical conditions. Some of the included potential confounding variables were socio-demographic characteristics: maternal age, religion, ethnicity, household wealth status, education of respondents, education of husband, marital status and occupation; obstetrics and some medical factors: parity, history of abortion (bleeding during pregnancy), history of preterm birth, history of stillbirth, unwanted pregnancy, hypertensive disorders in pregnancy [47](chronic hypertension, preeclampsia-eclampsia, preeclampsia superimposed on chronic hypertension, and gestational hypertension), gestational diabetes, Mid-Upper Arm Circumference (MUAC), and sex of infant and behavioral Addila et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:64 Page 4 of 15 Fig. 1 Flowchart of the study participants at Gondar town public health facilities, Northwest Ethiopia, 2020 variables: cigarette smoking, coffee intake, khat chewing were evaluated. booking ultrasound scan estimate was not preferred, they were also excluded from the study. Exposure ascertainment and alcohol use measures Participant selection and recruitment Women were enrolled and a baseline interview was executed if they were in the first 2 weeks of the third trimester or 28th weeks of gestational age. Because if the baseline data were collected and study participants were advised to stop alcohol intake in the first or/and second trimesters, they might not give the right information about alcohol use in the next interview that may underestimate and lead to false-negative outcomes. The postpartum interview was carried out following delivery, typically in the health facility during the postpartum stay or within 48 h of delivery. All mother-newborns pairs in Gondar town were a source population, and pregnant women who were sampled in the selected health facilities were the study participants. Medical health facility documents or log booklets for infants and mothers were reviewed to collect necessary information related to delivery, selected medical risk factors, and some potential confounders. The eligible study participants in the follow-up were restricted to a singleton pregnancy and aged 18 years or above. If the birth outcomes were not well known due to giving birth at their home or incomplete registration, they were excluded from the study. If a woman was uncertain in remembering the first day of the last menstrual period, the cycle was irregular or there was a difference of more than 7 days, and a To ascertain fetal alcohol exposure, we used maternal self-reporting that is the most common clinical instrument and standard in detecting alcohol exposure [48]. Information on alcohol intake during pregnancy was collected for specific trimesters of pregnancy during baseline prenatal and postpartum interviews. During the baseline interview, study participants were asked in detail about alcohol use information during the first and second trimesters, including the type and quantity of alcoholic beverages. Drinking information of the third trimester was collected in the postpartum interview. For each type of alcoholic beverage, pregnant women were asked how often they consumed alcohol and the number of drinks they drank during the specific trimester based on the AUDIT-C questionnaire [49–51].AUDIT-C is the most popular shortened version of the 10-item AUDIT that comprises three items to assess alcohol consumption cross-culturally and identify hazardous drinkers [49, 52]. The tool had shown to be a valid instrument for alcohol consumption since pregnancy recognition based on self-report [53]. The questionnaire was adjusted by considering the local context of alcoholic beverages of alcohol content and drinking containers. The amount of alcohol content in a standard drink varies from country to country; we used the WHO’s standard for this study since Ethiopia has no national alcohol policy defining Addila et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:64 standard alcohol drinks [54]. Based on this, for a standard drink, 12 g of absolute alcohol was assumed which was considered as alcohol consumption. A standard drink was determined by converting local drinks to grams of pure alcohol, and then we specified the amount of pure alcohol per local drink and using local units of measure. For this study, participants were categorized as abstainers or non-drinkers if women reported that they have never drunk any alcoholic beverages entirely throughout pregnancy, (AUDIT-C score = 0), low-risk drinkers, or non-hazardous drinkers if they reported 1 or 2 scores in AUDIT-C for the period of pregnancy) [55], and hazardous drinkers if they consumed a pattern or quantity of alcohol with an AUDIT-C score of three or more [56–58]. Different receptacles were used to measure local drinks, such as ‘tassa’, malekia’ and ‘birille’ for drinks Tella (traditional Ethiopian beer fermented from mostly barley but also with wheat, maize, sorghum, and mixed with ‘Gesho’ [Rhamnusprinioides]) [33], Areki (a whiskey-like drink distilled from fermented barley or maize and mixed with ‘[Rhamnusprinioides]) and Tej (a honey wine), respectively. The amount of each drink consumed in ml was then calculated. This value was converted to grams of absolute alcohol by applying a conversion factor and taking into account the percentage of absolute alcohol present in each drink. Accordingly, a standard drink equivalent to 1 bottle beer (330 ml) at 5% x (strength) 0.79 (conversion factor) = 13 g of ethanol; 1 glass wine (140 ml) at 12% × 0.79 = 13.3 g of ethanol; 1 shot (‘malekia’) Areki(40 ml) at 40% × 0.79 = 12.6 g of ethanol, alcoholic content (30–50%); 1 ‘birille’ Tej (200 ml) at 8% × 0.79 = 12.64 g of ethanol, alcoholic content (7–11%);and 1 “tassa” Tella/Korofe (330500 ml) at 4.5% × 0.79 = 11.73 g of ethanol of alcoholic content (4–6%) [59–61]. Data collection methods and tools This data collection tool was similar to a previous article, a nested case-control study, which was part of this project published elsewhere [62]. The questionnaire was prepared first in English and then translated into Amharic (local language) to suit local applicability and then back to English to ensure its consistency. The tool was developed by reviewing different previous studies of similar objectives [2, 50, 51, 63–66], and then experts’ consultation was sought to ascertain its validity by considering the local situation of the study participants and clinical relevance. Data were collected using a standardized interviewer-administered questionnaire and reviewing maternal care logbooks at the health facilities. A detailed interview was done for each woman in private with a nurse or a midwife at the baseline using a pretested interviewer administrated questionnaire. Data Page 5 of 15 collectors and supervisors trained on data collection tools, procedures during data collection, obtaining consent from participants, and not missing any questions in the questionnaire. The Amharic version questionnaire was pre-tested for clarity through a pilot study on 67 respondents in Bahir Dar town, which is 180 km away from the actual study area. The tool was checked for its reliability and validity before actual data collection. To assure data truthfulness, weekly meetings and daily supervision were conducted with supervisors and data collectors to observe the quality, status, and issues in collecting data. In addition to AUDIT-C, the tool also included the Edinburgh Postnatal Depression Scale (EPDS), which has 10 items scored on a scale of 0–3; the score ranging from 0 to 30, and we used a cut-off point of 13 and above on the scale to identify women with depressive symptoms [67]. The socio-economic status of the households (wealth index) was assessed using 16 variables extracted from Ethiopia Demographic and Health Survey 2016, and Principal Component Analysis was computed to determine it. The MUAC of the left arm with no clothing was measured in the third trimester using a flexible nonstretchable standard tape measure. Pregnant women having MUAC< 22 cm were considered undernourished and ≥ 22 cm normal [68]. When the hemoglobin level was less than 11.0 g/dl during the first or third trimester, the presence of anemia was considered [69]. Statistical analysis The data were entered using into EpiData 3.1.version and exported to STATA version 14. We computed bivariable log-binomial regression model analysis to see the association of selected maternal characteristics and prenatal alcohol use (non-hazardous and hazardous) with primary outcomes of interest using the chi-square test statistic. All variables significantly associated with outcomes of interest in bivariable analysis at p-value ≤0.2 were considered as candidates for the multivariable log-binomial regression model. In the final model, multivariable analysis was performed to examine the association between reported prenatal alcohol exposure (nonhazardous and hazardous) and interested adverse birth outcomes. The strength of associations of the regression model was reported using an adjusted risk ratio (ARR) with a corresponding 95% confidence interval (CI) and the p-value < 0.05 to declare the statistical significance threshold. The occurrence of multicollinearity among explanatory variables was ensured using the Variance Inflation Factor (VIF) at a cut-off point of 10 [70]. Complete case analyses were carried out by taking out any cases with a missing covariate. We used the adjusted PAR to determine the proportion of adverse birth outcomes that would not occur in a population if alcohol Addila et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:64 consumption were eliminated in the entire cohort after adjustment for potential confounders. This method first estimates the risk ratio for the alcohol consumption and for potential confounders and then estimates the number of events expected if the exposure of interest were eliminated to derive the percentage of outcomes attributable to alcohol consumption. The proportion of LBW, preterm birth, and stillbirth outcomes that could be attributed to maternal pregnancy alcohol consumption was estimated using Levin’s formula: PAR % = P*(ARR–1) / [P*(ARR–1) + 1] *100, where P was the proportion of women who used alcohol (hazardous or non-hazardous drinkers) during pregnancy, and ARR was the adjusted risk ratio of the adverse birth outcomes associated with the alcohol consumption [71, 72]. Ethical considerations Ethical clearance was obtained from the Institutional Ethical Review Board of the University of Gondar (R. No.-O/V/P/RCS/05/747/2019), and permission was received from Amhara Public Health Institute and Gondar town health department before the start of the study. Before enrolment of the participants, all respondents were informed about the importance of the study, its objective, effects, and the significance of participation. Verbal informed consent was also obtained before conducting data collection and all information was completed to maintain confidentiality. After taking the necessary information, all participants were counseled about the risks of alcohol drinking during pregnancy and advised not to drink any alcohol during pregnancy or while trying to get pregnant. Besides, women who engaged in hazardous drinking were referred to healthcare providers and proper linkage was established to get possible treatment options in their respective health facilities. Page 6 of 15 Reproductive and medical history related characteristics of the study participants Almost half, (49.23%) of the study participants had one or two children. Concerning birth intervals, the majority (81.91%) of pregnant women had 24 months and above birth intervals. More than half, (60.50%) of the women had experienced at least one previous birth (multiparous). Two hundred ten (12.46%) of the respondents had experienced a history of abortion. Among the study participants who were tested for hemoglobin level, 248(14.86%) of the pregnant women had anemia (Table 2). Alcohol consumption during pregnancy Among women who used alcohol of the study participants, approximately one-fifth (20.57%) reported taking hazardous alcohol during their current pregnancy. Five hundred thirty-eight (95.39%) of the alcohol drinkers used alcoholic beverages in the first trimester, 548(97.16%) and 539(95.57%) consumed in the second and third trimesters, respectively. Regarding the amount of alcohol consumption, 98(17.38%) of the respondents used six or more drinks on one occasion during their current pregnancy. Likewise, most pregnant women (68.62%) consumed one or two standard drinks, 21.10% had three or four drinks, and 10.28% of the participants had five or more standard drinks on a typical day. Concerning the types of alcoholic beverages that were consumed by respondents, the most commonly used alcoholic beverage in the first trimester was Tella(56.03%), followed by beer/draft (19.15%). In the second trimester, 39.18, 31.74, 3.55, 2.30, and 20.39% of the respondents consumed beer/ draft, Tella, wine, Areki/Tej/Korofe, and two or more types of drinks, respectively. Finally, types of alcoholic beverages which were consumed in the third trimester were beer/draft (35.64%), Tella (31.21%), Areki/Korofe/ Tej/wine (5.33%), and two or more types of drinks (23.94%) (Table 3). Results Birth outcomes Socio-demographic characteristics of the participants The mean birth weight of newborns who were delivered from singleton pregnancies was 2994.68 ± 433.02 g, and the gestational age of newborns was 38.84 ± 1.66 weeks. The incidence of low birth weight in the whole cohort (weighed less than the 2500 g) was 12.63% (95% CI: 11.12, 14.31). Likewise, the incidence of preterm (< 37 weeks gestation) and stillbirth were 6.05% (95% CI: 5.00, 7.29) and 4.27% (95% CI: 3.4, 5.35), respectively. A total of 1778 pregnant women were enrolled in the study, and of these, 1686 had data available on birth outcomes. We excluded 92 mother-infant pairs from the analysis due to missing appropriate birth outcome data (Fig. 1). The mean maternal age at the baseline was 26.47 ± 4.58 years. Nearly two-thirds (60.8%) of the study participants were between the ages 25 and 34 years. Most of the women were married (97.4%) and were orthodox (88.2%). Three hundred sixty-six (21.7%) of them had no formal education, and only 510(30.2%) had tertiary education (Table 1). Relationship between the level of alcohol intake and birth outcomes Overall, there was some difference between the adverse birth outcomes for infants of mothers who drank any Addila et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:64 Page 7 of 15 Table 1 Socio-demographic and economic characteristics of study participants in Gondar town, Northwest Ethiopia, 2020 (n = 1686) Variables Intensity of alcohol consumption Non-drinkers n = 1122 (66.5%) Non-hazardous n = 448 (79.4%) Total (%) Hazardous n = 116 (20.6%) Health facilities University of Gondar comprehensive specialized hospital 542(48.31) 239(53.35) 28(24.14) 809(47.98) Gondar polyclinic 211(18.81) 132(29.91) 38(32.76) 383(22.79) Azezo 229(20.41) 58(12.95) 42(36.21) 329(19.51) Maraki 148(12.48) 17(3.79) 8(6.90) 165(9.79) 15–24 378(33.24) 141(31.03) 30(25.86) 549(32.56) 25–34 661(58.91) 281(62.72) 76(65.52) 1018(60.38) ≥ 35 83(7.40) 26(5.80) 10(8.62) 119(7.06) Married 1094(97.50) 434(96.88) 114(98.28) 1642(97.39) Single/divorced/separated/widowed 28(2.50) 14(3.13) 2(1.72) 44(2.61) Orthodox 933(83.16) 438(97.77) 116(100) 1487(88.20) Muslim 179(15.95) 7(1.56) 0(0.00) 186(11.03) Protestant 10(0.89) 3(0.67) 0(0.00) 13(0.77) Amhara 1070(95.37) 433(96.65) 144(98.28) 1617(95.91) Others 52(4.63) 15(3.35) 2(1.72) 69(4.09) 417(37.17) 180(40.18) 46(39.66) 643(38.14) Age group (years) Marital status Religion Ethnicity Family size 1–2 3–4 574(51.16) 220(49.11) 61(52.59) 855(50.71) ≥5 131(11.68) 48(10.71) 9(7.76) 188(11.15) No formal education 233(20.77) 101(22.54) 32(27.59) 366(21.71) Primary education (Grade 1–8) 167(14.88) 63(14.06) 17(14.66) 247(14.65) Secondary education(Grade 9–12) 385(34.31) 141(31.47) 37(31.90) 563(33.39) Tertiary education(above Grade 12) 337(30.04) 143(31.92) 30(25.86) 510(30.25) The educational level of respondents Occupation Housewife 525(46.79) 189(42.19) 64(55.17) 778(46.14) Employed in any organization 233(20.77) 116(25.89) 32(27.59) 264(21.79) Merchant 247(22.01) 122(27.23) 13(11.21) 382(22.66) Students 75(6.68) 6(1.34) 1(0.86) 82(4.86) Others 42(3.74) 15(3.35) 6(5.17) 63(3.74) Poorest 260(23.17) 80(17.86) 9(7.76) 349(20.70) Poor 225(20.05) 85(18.97) 33(28.45) 343(20.34) Middle 198(17.65) 97(21.65) 20(17.24) 315(18.68) Rich 225(20.05) 90(20.09) 26(22.41) 341(20.23) Richest 214(19.07) 96(21.43) 28(24.14) 338(20.05) Household wealth index Addila et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:64 Page 8 of 15 Table 2 Reproductive and medical history related characteristics of study participants attending ANC at public health facilities in Gondar town, Northwest Ethiopia, (n = 1686) Variables The intensity of alcohol consumption Total (%) Non-drinkers n = 1122 (66.5%) Non-hazardous n = 448 (79.4%) Hazardous n = 116 (20.6%) Male 543(48.40) 218(48.66) 51(43.97) 812(48.16) Female 579(51.60) 230(51.34) 65(56.03) 874(51.84) No child yet 446(39.75) 189(42.19) 45(38.79) 680(40.33) 1–2 children 544(48.48) 223(49.78) 63(54.31) 830(49.23) ≥3 132(11.76) 36(8.04) 8(6.90) 176(10.44) < 24 months 145(21.14) 28(11.20) 9(12.86) 182(18.09) ≥ 24 months 541(78.86) 222(88.80) 61(87.14) 824(81.91) < 22 cm 143(12.75) 84(18.75) 26(22.41) 253(15.01) ≥ 22 cm 979(87.25) 364(81.25) 90(77.59) 1433(84.99) Yes 127(11.32) 66(14.73) 17(14.66) 210(12.46) No 995(88.68) 382(85.27) 99(85.34) 1476(87.54) Sex of the newborn Number of children Birth interval (n = 1006) MUAC History of abortion History of preterm birth (n = 1020) Yes 28(4.14) 13(4.71) 7(9.72) 48(4.71) No 648(95.86) 259(95.22) 65(90.28) 972(95.29) Yes 195(17.38) 71(15.85) 44(37.93) 310(18.39) No 927(82.62) 377(84.15) 72(62.07) 1376(81.61) Depression History of known diabetes mellitus Yes 12(1.07) 5(1.12) 3(2.59) 20(1.19) No 1110(98.93) 443(98.88) 113(97.41) 1666(98.81) Yes 147(13.21) 62(13.96) 39(34.82) 248(14.86) No 966(86.79) 382(86.04) 73(65.18) 1421(85.14) Anemia(n = 1669) Hypertensive disorders in pregnancy Yes 88(7.84) 55(12.28) 20(17.24) 163(9.67) No 1034(92.16) 393(87.72) 96(82.76) 1523(90.33) Yes 839(74.78) 331(73.88) 86(74.14) 1256(74.50) No 283(25.22) 117(26.12) 30(25.86) 430(25.50) Drinking coffee Smoking Yes 2(0.18) 2(0.45) 2(1.72) 6(0.36) No 1120(99.82) 446(99.55) 114(98.28) 1680(99.64) Yes 15(1.34) 8(1.79) 2(1.72) 25(1.48) No 1107(98.66) 440(98.21) 114(98.28) 1661(98.52) Khat chewing Addila et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:64 Table 3 Alcohol intake during pregnancy using Alcohol Use Disorders Identification Test- Consumption (AUDIT-C) Variables Number (percent) How often do you have a drink containing alcohol during your current pregnancy (n = 1686) (0) Never 1122(66.55%) (1) Monthly or less 345(61.17%) (2) 2 to 4 times a month 151(26.77%) (3) 2 to 3 times a week 66(11.70%) (4) 4 or more times a week 2(0.35%) How many drinks containing alcohol do you have on a typical day when you are drinking during pregnancy? (n = 564) (0) 1 or 2 387(68.62%) (1) 3 or 4 119(21.10%) (2) 5 or 6 43(7.62%) (3) 7, 8, or 9 15(2.66%) (4) 10 or more 0(0.00%) How often do you have six or more drinks on one occasion during your current pregnancy? (n = 564) (0) Never 466(82.62%) (1) Less than monthly 67(11.88%) (2) Monthly 29(5.14%) (3) Weekly 2(0.35%) (4) Daily or almost daily 0(0.00%) levels of alcohol during pregnancy and women who were abstinent during pregnancy. Alcohol consumption during pregnancy had dose-response relationship with the risk of low birth weight (10.25% for no consumption, 15.18% for non-hazardous, and 25.86% for hazardous consumption at chi-square = 26.80, P < 0.001) and preterm delivery (5.53% for no consumption, 5.58% for non-hazardous, 12.93% for hazardous consumption at chi-square = 10.38, P < 0.001). On the other hand, there was an inconsistency of dose-response relationship for stillbirth between babies born to mothers of alcoholconsuming and women who did not (4.28% for no consumption, 3.13% for non-hazardous, 8.62% for hazardous consumption at chi-square = 6.81, P = 0.033). Women who reported a hazardous pattern of alcohol intake during pregnancy were 2.34 times (ARR = 2.34; 95% CI: 1.66, 3.30) increased the risk of low birth weight when compared to women who abstained entirely throughout pregnancy. Similarly, the risk of LBW was 50% (ARR = 1.50; 95% CI: 1.31, 1.98) higher for nonhazardous alcohol drinker pregnant women when compared to women who did not consume any alcohol. Analysis of the hazardous level of alcohol consumption during pregnancy yielded 2.06 times (ARR = 2.06; 95% CI: 1.21, 3.52) increased the risk of preterm birth compared to abstinent during pregnancy, but the association Page 9 of 15 was not observed at non-hazardous levels of alcohol use during pregnancy (Table 4). The adjusted PAR of low birth weight related to non-hazardous and hazardous alcohol drinking during pregnancy was 11.72 and 8.44%, respectively, while the adjusted PAR of hazardous alcohol consumption was 6.80% for preterm. Before adjusting for potential confounders, the association between stillbirth and the hazardous level of alcohol consumption was found to be two-fold (RR = 2.01; 95% CI: 1.05, 3.88) higher than abstinent during pregnancy. However, there was no evidence of an increased likelihood of stillbirth at any levels of alcohol consumption during pregnancy after adjustment for other covariates (Table 5). Discussion To the best of our knowledge, this is the first prospective cohort study regarding maternal alcohol consumption in Ethiopia that looked at hazardous and non-hazardous alcohol exposures during pregnancy separately and their association with adverse birth outcomes. Maternal alcohol consumption during pregnancy in many countries continues to be the single most important modifiable risk factor for adverse birth outcomes. This study examined the potential effects of alcohol (hazardous and nonhazardous) consumption during pregnancy on adverse birth outcomes. In the present study, we found the risk of low birth weight significantly increased among newborns of mothers who drank both hazardous and nonhazardous alcohol during pregnancy. Likewise, there was a statistically significant association between hazardous alcohol intake and preterm birth. However, there was no evidence of the association between alcohol consumption during pregnancy and stillbirth had been observed after taking into account other covariates. In addition to alcohol consumption, other risk factors associated with low birth weight: education level, household wealth status, family size, anemia in pregnancy, and MUAC; and preterm birth: occupation, hypertensive disorder of pregnancy, and sex of the newborn. Stillbirth was associated with family size, anemia, and preterm birth. Findings from our study showed that an increasing trend in the risk of low birth weight with increasing levels of alcohol exposure was statistically significant. In this cohort study, prenatal hazardous and nonhazardous alcohol exposures were 2.34 times and 50% more likely to increase the risk of low birth weight compared to abstainers, respectively. On the other hand, the analyses of adjusted PAR percent also showed that 8.44and 11.72% of low birth weight cases might be attributed to hazardous and non-hazardous alcohol consumption, respectively. Some studies have concordantly found that maternal prenatal alcohol exposure was negatively associated with the weight of newborns [37, 73, Addila et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:64 Page 10 of 15 Table 4 Associations between alcohol consumption during pregnancy, and some maternal characteristics and adverse fetal outcomes at public health facilities in Gondar town, Northwest, Ethiopia, 2020 Variables Low birth weight Yes No 15–24 91(16.58) 458(83.42) 25–34 108(10.61) 910(89.39) ≥ 35 14(11.76) 105(89.24) No formal education 40(10.93) Primary education Secondary education Tertiary education RR (95% CI) ARR (95% CI) Preterm RR (95% CI) ARR (95% CI) 1 Yes No 44(8.01) 505(91.99) 1 0.64(0.49, 0.83) 0.80(0.59,1.08) 48(4.72) 970(95.28) 0.59(0.40, 0.87) 0.68(0.43,1.07) 0.71(0.42, 1.20) 0.89(0.47,1.67) 10(8.40) 109(91.60) 1.05(0.54, 2.02) 0.98(0.40,2.20) 326(89.07) 0.94(0.64, 1.57) 1.50(1.01,2.23) 35(9.56) 331(90.44) 2.32(1.38,3.92) 40(16.19) 207(83.81) 1.40(0.97, 2.03) 1.34(0.92,1.94) 18(7.29) 229(92.71) 1.77(0.96, 3.26) 0.98(0.49,1.99) 74(13.14) 489(86.86) 1.14(0.82, 1.57) 1.44(0.92,2.25) 28(4.97) 535(95.03) 1.21(0.69, 2.10) 0.80(0.43,1.48) 59(11.57) 451(88.43) 1 1 21(4.12) 489(95.88) 1 Age of the mother 1 1 Education level 1.45(0.78,2.68) 1 Occupation Merchant 19(13.97) 117(86.03) 1 1 10(2.62) 372(97.38) 1 1 Housewife 56(20.97) 211(79.03) 1.44(1.02,2.02) 1.83(0.83,1.68) 69(8.78) 709(91.13) 3.39(1.77,6.50) 2.87(1.47,5.62) Employed in any organization 20(13.07) 133(86.93) 1.05(0.70,1.60) 0.92(0.59,1.43) 14(3.67) 367(96.33) 1.40(0.63,3.12) 1.40(0.61,3.24) Others 5(17.86) 23(82.14) 1.28(0.77,2.15) 1.09(0.64,1.84) 9(6.21) 136(93.79) 2.37(0.98,5.72) 1.98(0.97,2.34) Poorest 39(11.17) 310(88.83) 1 1 – – – – Poor 54(15.74) 289(84.26) 1.4(0.96, 2.07) 1.26(0.86,1.85) – – – – Middle 20(6.35) 295(93.65) 0.57(0.34, 0.95) 0.57(0.34,0.96) – – – – Household wealth status Rich 49(14.37) 292(85.63) 1.29(0.87, 1.91) 1.23(0.84,1.83) – – – – Richest 51(15.09) 287(84.91) 1.35(0.91, 1.99) 1.05(0.69,1.59) – – – – 97(15.09) 546(84.91) 1 1 50(7.78) 593(92.22) 1 1 Family size 1–2 3–4 94(10.99) 761(88.01) 0.73(0.56, 0.95) 1.86(1.24,2.80) 38(4.58) 817(95.56) 0.57(0.38, 0.86) 0.73(0.34,1.57) 5 and above 22(11.70) 166(88.30) 0.76(0.50, 1.19) 2.21(1.21,4.00) 14(7.45) 174(92.55) 0.96(0.54, 1.69) 1.00(0.33,3.01) Parity Nulliparous 113(16.97) 553(83.03) 1.73(1.35,2.22) 2.53(1.68,3.82) – – – – Multiparous 100(9.8) 920(90.20) 1 1 – – – – No child yet – – – – 51(7.50) 629(92.50) 1 1 1–2 – – – – 38(4.58) 792(95.42) 0.61(0.41, 0.92) 0.96(0.43,2.12) ≥3 – – – – 13(7.39) 163(92.61) 0.98(0.55, 1.76) 1.06(0.33,3.41) Planned 176(12.07) 1282(87.93) 1 Un planned 37(16.23) Number of children Status of pregnancy 1 – – – – 191(83.77) 1.34(0.97,1.86) 1.23(0.89,1.71) – – – – 1.50(0.87, 2.55) 1.97(1.14,3.39) Hypertensive disorders of pregnancy Yes – – – – 14(8.59) 149(91.41) No – – – – 88(5.78) 1435(94.22) 1 Hazardous 30(25.86) 86(74.14) 2.52(1.77, 3.59) 2.34(1.66, 3.30) 15(12.93) 101(87.07) 2.34(1.38, 3.98) 2.06(1.21,3.52) Non- hazardous 68(15.18) 380(84.82) 1.48(1.12, 1.96) 1.50(1.31,1.98) 1.01(0.64, 1.59) 1.03(0.66,1.62) Non-drinker 115(10.25) 1007(89.75) 1 1 Alcohol consumption 1 25(5.58) 423(94.42) 62(5.53) 1060(94.47) 1 1 Addila et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:64 Page 11 of 15 Table 4 Associations between alcohol consumption during pregnancy, and some maternal characteristics and adverse fetal outcomes at public health facilities in Gondar town, Northwest, Ethiopia, 2020 (Continued) Variables Low birth weight RR (95% CI) ARR (95% CI) Yes No Male – – – Female – – – Yes 48(19.35) 200(80.65) 1.69(1.26, 2.26) 1.65(1.24,2.21) No 163(11.47) 1258(88.53) 1 Preterm RR (95% CI) ARR (95% CI) Yes No – 62(7.64) 750(92.36) 1 1 – 40(4.58) 834(95.42) 1.67(1.13,2.45) 1.55(1.05,2.27) Sex of newborn Anemia – – – – 1 – – – – 1 – – – – – Advise the risks of alcohol use during ANC visit Yes 37(9.05) 372(90.95) 1 No 176(13.78) 1101(86.22) 1.52(1.09, 2.13) 1.32(0.94,1.84) – – – < 22 cm 48(18.75) 24(8.98) 232(90.63) 1.72(1.11, 2.66) 1.51(0.97,2.34) ≥ 22 cm 165(11.54) 1265(88.46) 1 78(5.45) 1352(94.55) 1 MUAC 208(81.25) 1.63(1.21, 2.18) 1.47(1.09,1.97) 1 74]. Similarly, our study is consistent with several studies examining higher levels of prenatal alcohol consumption that have been linked with low birth weight [1, 9, 39]. Simultaneously, non-hazardous or light to moderate alcohol consumption during pregnancy had a positive 1 significant association with the risk of low birth weight. This finding agreed with previous results of other studies that found low weight in newborns that were prenatally exposed to low to moderate maternal drinking [75–77]. The reason for this association could be justified that Table 5 Associations between alcohol consumption during pregnancy, and some maternal characteristics and stillbirth at public health facilities in Gondar town, Northwest, Ethiopia, 2020 Variables Stillbirth Yes No 37(5.75) 606(94.25) RR (95%CI) ARR (95% CI) 1 1 Family size 1–2 3–4 31(3.63) 824(96.37) 0.63(0.39, 1.00) 0.44(0.18,1.07) 5 and above 4(2.13) 184(97.87) 0.37(0.13, 1.02) 0.23(0.06,0.83) Nulliparous 35(5.26) 631(94.74) 1.45(0.92,2.27) 0.61(0.25,1.47) Multiparous 37(3.63) 983(96.37) 1 1 Parity Alcohol consumption Hazardous 10(8.62) 106(91.38) 2.01(1.05, 3.88) 1.64(0.84,3.22) Non- hazardous 14(3.13) 434(96.88) 0.73(0.41,1.31) 0.72(0.40,1.29) Non-drinker 48(4.28) 1074(95.72) 1 1 – Anemia Yes 17(6.85) 231(93.15) 1.77(1.05, 3.00) 1.72(1.00,2.96) No 55(3.87) 1366(96.13) 1 1 Yes 12(11.76) 90(88.24) 3.11(1.73, 5.58) 2.99(1.65,5.41) No 60(3.79) 1524(96.21) 1 1 < 2500 g 13(6.10) 200(93.90) 1 1 ≥ 2500 g 59(4.01) 1414(65.99) 152(0.85,2.73) 1.14(0.63,2.10) Preterm birth Birth weight Addila et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:64 alcohol consumption during pregnancy impairs placental growth, lead to vasoconstriction, and interferes placental transmission of necessary nutrients and sufficient oxygen to the fetus [78]. On the contrary, some studies conducted in various areas detected no association between non-hazardous alcohol consumption and low birth weight [1, 26]. The possible explanation for this disagreement might be the difference in genetic material or biological variation for alcohol absorption and metabolism in the mothers and their fetus, data collection tools or methods, a cut-off value for low to a moderate level, characteristics of the study participants, lack of consistent definition for non-hazardous or low to moderate alcohol use and timing of consumption [79, 80]. Another potential reason for variation could be the heterogeneity of the quality of alcohol consumed; in our study, the majority of alcoholic drinks were locally prepared or homemade, which are prone to contamination with methanol and has high alcohol-related harm [12, 81]. Also, there might be the failure to adjust appropriately or differences in adjustment for possible confounding covariates between the studies, and residual confounding might have been a problem in some studies because of incorrectness in measuring confounders. Similarly, based on our analysis, alcohol consumption during pregnancy has a dose-response relationship with preterm birth. We have attempted to provide the public health burden of hazardous alcohol consumption for preterm by quantifying PAR percent. We also found an association of hazardous prenatal alcohol drinking with preterm delivery compared to abstainers during pregnancy after adjusting for possible confounding factors. The finding showed that preterm birth was higher among women who reported hazardous alcohol consumption (AUDIT-C score ≥ 3) implies that exposure to excess alcohol during pregnancy has the potential to premature delivery. This result is consistent with the findings of other earlier studies that found preterm birth in neonates who were prenatally exposed to hazardous or heavy maternal drinking [38, 82]. The possible clarification for this link could be due to the association of prenatal alcohol exposure with placental dysfunction, diminished placental size, impaired blood flow and important nutrient transportation, and endocrine changes, any of which could play a role in the alcohol exposure effects on preterm birth [78]. On the other hand, the present finding is not in line with the result of other studies [76]. Our study could not find the effect of nonhazardous alcohol consumption on the risk for preterm delivery. This finding is consistent with previous studies of low to moderate alcohol exposure [83–85] and a systematic review of low-to-moderate alcohol consumption [26]. However, our result lacked the concordance with a prospective cohort study among mother-child pairs that Page 12 of 15 demonstrated a light and mild level of maternal alcohol intake during pregnancy was positively associated with the risk of preterm birth [86]. The possible explanations for the discrepancy of our finding with earlier studies could be methods of assessment of maternal alcohol intake during pregnancy and variation in classifications of alcohol consumption (e.g. we categorized as non-drinker or abstainer, non-hazardous and hazardous based on AUDIT-C score, but others might not be similar to this). On the other hand, our study participants were not identical to the study participants of the previous studies with respect to biology and other characteristics that might cause the difference in susceptibility to adverse effects of alcohol use. On the other analysis, there was no statistically significant association between any levels of alcohol consumption during pregnancy and stillbirth. This finding is consistent with the studies conducted in various parts of the world [87]. However, there are some controversial findings in the relationship between alcohol consumption during pregnancy and stillbirth; they confirmed that there was a positive link between higher threshold prenatal alcohol exposure and stillbirth [88–90]. This lack of relationship might be due to the limited information received about dose and frequency of alcohol consumption, unobserved heterogeneity among the study participants, and differences in exposure ascertainment that make it difficult to compare our results with those of findings. Generally, the variations between our findings and other studies could be to some extent due to heterogeneity between studies related to the method of alcohol assessments and inconsistent choice of potential confounders. Furthermore, the discrepancy in findings between nations may be a reflection of differences in alcoholic beverages and drinking patterns. Lastly, differences might also be due to genetic variations linked to the metabolism of alcohol that may differ between populations [91]. Strengths and limitations of the study One of the strengths of this study is the clarification of a dose-response relationship between maternal prenatal alcohol consumption and adverse birth outcomes, including locally brewed alcohols. It is important that only limited evidence exists on the effect of non-hazardous alcohol levels of prenatal alcohol exposure on adverse birth outcomes. Another strength of this study is determining population attributable risk, which allows public health programmers to address what percent of adverse birth outcomes could be prevented if alcohol consumption during pregnancy were to be taken out from the pregnant women. Despite these strengths, due to the presence of some limitations, the findings of this study should be Addila et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:64 interpreted with caution. Alcohol consumption information was collected based on maternal self-report and hence is subject to recall bias. Women who consumed alcohol were more likely to either falsely refuse the alcohol use or significantly underreport the actual level that they drank and then could be categorized as non-drinker because drinking alcohol during pregnancy is considered socially unacceptable [92]. Thus, the reported amounts of alcoholic beverages consumed may be considerably lower than the real value biasing the study results due to misclassification and would under-estimate the true link between drinking and adverse birth outcomes, leading to a type II error. Nevertheless, self-report has been found to be more precise than other methods [93]. Most of the alcohol used was locally homemade brews; therefore, the exact volume of containers of alcohol was not well understood by the respondents, so it was difficult to get the factual standard drink during conversion. Conclusions and recommendations Our findings suggest that there is an increasing risk of adverse birth outcomes, particularly preterm delivery and low birth weight, with increasing the level of alcohol intake. This result showed that the prevention of maternal alcohol use during pregnancy has the potential to reduce low birth weight and preterm. Hence, screening women for alcohol use during ANC visits and provide advice with rigorous follow-up of women who used alcohol may save the fetus from the potential risks of adverse birth outcomes. Healthcare workers have maintained strong and consistent messages of alcohol abstinence for pregnant women. Healthcare professionals should always be supported by comprehensive and up-to-date information on prenatal alcohol use and incorporate such information to prevent alcohol use among women before they become pregnant [94]. The lack of an association between prenatal alcohol exposure and stillbirth in this study needs further investigation. Abbreviations ANC: Antenatal Care; AUDIT: Alcohol Use Disorders Identification Test; AUDITC: Alcohol Use Disorder Identification Test-Consumption; EPDS: Edinburgh Postnatal Depression Scale; FASD: Fetal Alcohol Spectrum Disorder; LAMP: Last Menstrual Period; MUAC: Mid-Upper Arm Circumference; PAR: Population-Attributable Risk; VIF: Variance Inflation Factor; WHO: World Health Organization Acknowledgments We thank the Gondar town health department, University of Gondar Comprehensive Specialized Hospital and, health centers for their provision of necessary information and support during data collection. Our genuine thanks also go to the study participants, data collectors, and supervisors who took part in the study. Authors’ contributions A.E conceptualized, designed, coordinated data collection, analyzed the data, and drafted the manuscript. T.A, Y.K, and M.Y designed the study and critically revised the manuscript. All authors read and approved the final manuscript. Page 13 of 15 Funding This study was funded by the University of Gondar and Wachemo University. The universities are following whether findings are presented and published. The universities have no role in the design, data collection, analysis and interpretation of the findings and in writing the manuscript. All the statements and findings are the responsibility of the investigators. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate Ethical approval was taken from the University of Gondar Institutional Ethical Review Board (R. No.-O/V/P/RCS/05/747/2019) and a permission letter was also obtained from the Gondar town health department. All the study participants were above 18 years. They were notified about the objective and verbal informed consent was obtained before conducting data collection. They were also informed that they had the full right to withdraw or refuse to participate in the study. No financial incentive was given to participants for their participation in the study. Data obtained from study participants were held anonymously and confidentially. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Author details 1 Department of Public Health, College of Medicine and Health Sciences, Wachemo University, Hossana, Ethiopia. 2Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia. 3Department of Health Education and Behavioral Sciences, College of Medicine and Health Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia. 4 Department of Health Systems and Policy, College of Medicine and Health Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia. 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Subst Use Misuse. 2010; 45(10):1474–90. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Nutrition 93 (2022) 111423 Contents lists available at ScienceDirect Nutrition journal homepage: www.nutritionjrnl.com Applied nutritional investigation Maternal stress during pregnancy and children’s diet: Evidence from a population of low socioeconomic status
le Belot Ph.D. d Nicolai Vitt Ph.D. a, Martina Vecchi Ph.D. b, Jonathan James Ph.D. c,*, Miche a University of Bristol, Bristol, United Kingdom Pennsylvania State University, State College, Pennsylvania University of Bath, Bath, United Kingdom d Cornell University, Ithaca, New York b c A R T I C L E I N F O Article History: Received 7 December 2020 Received in revised form 28 June 2021 Accepted 15 July 2021 Keywords: Diet Stress In-utero Food preferences A B S T R A C T Objectives: This study examined the relationship between maternal exposure to stress during pregnancy and children’s food preferences and diet in a population of low socioeconomic status. Methods: Indices of exposure to stress were constructed based on retrospective self-reported experience of stressful events during pregnancy (e.g., death of close family member, relationship difficulties, legal issues, health issues, financial issues, or other potentially stressful event[s]). Data were collected for >200 mothers
of a low socioeconomic status with a child age 2 to 12 y. Data on mothers’ body mass index, current exposure
to stress, current diet, and diet during pregnancy were collected at the same time, as well as data on children’s food preferences and current diet as reported by the mothers. Indices of the healthiness of food preferences and diet were constructed and used as outcome variables.
Results: Maternal exposure to stress during pregnancy significantly predicts children’s food and taste preferences, as well as their diet, in regression models controlling for maternal diet, current maternal stress, and
demographic characteristics of both the child and mother. Higher average stress during pregnancy is linked
with significantly less healthy food preferences and diet, as well as with weaker preferences for sour and bitter foods. This relationship is observed across different age groups.
Conclusions: Maternal exposure to stress during pregnancy could have long-term detrimental effects on dietary outcomes and thereby on health conditions related to diet. Prenatal care and preconception counseling
could be critical to develop preventive strategies to improve public health.
© 2021 Elsevier Inc. All rights reserved.
Introduction
The spread of obesity in developed nations over the past decades has disproportionally affected lower socioeconomic groups
because they face a larger risk of being overweight and obesity
[1
3]. Eating patterns and tastes particularly appear to be largely
formed early on in life (ie, during pregnancy and early childhood)
[4], and previous evidence has suggested that parental socioeconomic status (SES) has a direct impact on the probability of children being obese [5].
This study explores a specific pathway possibly linking parental
SES to a child’s diet: Maternal stress during pregnancy. Research in
medicine and epidemiology has highlighted the role of maternal
stress during pregnancy and the resulting hormonal processes in
determining children’s obesity risk in later life via so-called fetal
*Corresponding author. Tel.: +44 (0) 1225 385557
E-mail address: j.james@bath.ac.uk (J. James).
https://doi.org/10.1016/j.nut.2021.111423
0899-9007/© 2021 Elsevier Inc. All rights reserved.
programming [6
9]. Fetal programming of the metabolic system
emphasizes the importance of the intrauterine environment in
determining health outcomes during childhood and even adulthood.
Evidence based on animal and human studies [6] has shown that in
utero stress increases the risk of obesity and related conditions.
Stress-induced hormonal and immune processes have been suggested as channels for these effects on the fetus. The evidence suggests that experience of severe stress during pregnancy may, for
example, lead to dysregulated glycemic control or energy homeostatic balance. Whether these processes increase the risk of obesity
only by affecting the development of the child’s metabolic system or
whether they also change the child’s food preferences is unclear.
A second possible channel linking in utero exposure to stress
and children’s diet is through the neurologic development or programming of neurologic functions in utero. One hypothesis is that
in utero exposure to stress could result in the persistent programming of the hypothalamic
pituitary
adrenal (HPA) axis hyperresponsiveness, which in turn affects preferences for comfort foods
2
N. Vitt et al. / Nutrition 93 (2022) 111423
later in life [10]. Chronic stress is well known to be related to the
chronic stimulation of the HPA axis and the glucocorticoid secretion from the adrenal gland [11,12]. Intake of high energy foods (ie,
comfort eating) suppresses the hyperactivity of the HPA axis. Also,
there is a body of evidence showing that if a mother is stressed
while pregnant, her child is substantially more likely to have emotional or cognitive problems, including an increased risk of attention deficit/hyperactivity, anxiety, and language delay [13].
Plausibly, emotional and cognitive problems could increase the
risk of emotional eating and thereby contribute to unhealthy eating patterns in the child [14].
In addition to these neurologic, hormonal, and immune processes described, stress may affect a mother’s dietary choices during pregnancy and early childhood, which in turn are primary
influences on the formation of children’s food preferences [15].
Empirical evidence supports a link between stress and nutrition
during pregnancy. In animals, stress and nutrition during pregnancy have also been linked with adverse metabolic outcomes of
offspring [16]. In humans, gustatory and olfactory systems emerge
in utero and are functionally mature before birth [17], providing
opportunities for early sensory learning and shaping early preferences, as supported by animal studies [18,19].
A recent review by Lamichhane et al. [20] has found that subjective prenatal stress caused by exposure to natural disasters is
linked to offspring obesity, but studies with biomarkers of stress
showed mixed results. Based on the existing evidence, in utero
exposure to stress is a plausible pathway to obesogenic food preferences. However, to our knowledge, there have been no human
studies linking in utero stress exposure to food preferences and
diet during childhood.
The literature has also proposed that higher levels of stress
among populations from lower socioeconomic backgrounds could
be a factor behind the socioeconomic gradient in obesity [21,22].
Evidence based on observational data has shown that some individuals exposed to chronic stressors have a less balanced diet and
increased calorie intake [14]. Laboratory experiments have shown
that acute stress shifts individuals’ food choices toward a less
healthy diet with higher consumption of sugars and fat and a
higher total calorie intake [23,24]. Evans et al. [25] showed that
exposure to stress during childhood is associated with lower selfregulation and a higher body mass index (BMI).
In this study, we examined the relationship between maternal
stress during pregnancy and children’s food preferences and their
diet. Indices were constructed to measure the healthiness of each.
Stress during pregnancy was assessed using retrospective selfreported information on stressors experienced during pregnancy
and their perceived stressfulness. Additional data on possible confounding factors, such as the mothers’ current stress and diet and
the mother’s diet during pregnancy, were collected at the same
time. These confounding factors were controlled for in our analysis.
Methods
Participants
Participants were 213 mothers of low SES living in the area of Colchester,
United Kingdom, who were taking part in a larger stu…

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